Pragmatic randomized clinical trials: best practices and statistical guidance

Effectiveness of group-delivered cognitive behavioural therapy for insomnia in primary care: a pragmatic, multicentre randomised controlled trial

Insomnia is a prevalent disorder in the general population. Group delivery increases access to the treatment of choice for insomnia, cognitive-behavioural therapy for insomnia (CBT-I). The aim of this pragmatic randomized controlled trial was to investigate the effectiveness of low-threshold group-delivered CBT-I implemented in Norwegian primary care. The trial was registered in the ISRCTN registry (ISRCTN16185698), and conducted across 26 Healthy Life Centres. Inclusion criteria were age ≥ 18 years and insomnia symptoms with a significant impact (Insomnia Severity Index (ISI) ≥ 12). Eligible participants were randomized to group-delivered CBT-I or to a waiting list according to a 2:1 ratio. The intervention consisted of four 2-h sessions over 4 weeks, with 5-15 participants per group. Primary outcome was self-reported insomnia severity at 3-months follow-up, measured by the ISI. Participants were not blinded to group assignment, but those responsible for analyses and interpretation of the results were. In total, 308 participants were randomly allocated to group-delivered CBT-I (n = 181) or waiting list (n = 127). The mean difference in ISI score between groups at 3-months follow-up was -3.4 (95 % CI: 4.3 to -2.5), favoring the group-delivered CBT-I. Of those receiving group-delivered CBT-I, 51 (33.6 %) reported a clinically relevant improvement in insomnia severity (i.e., ≥ 8 points on ISI), compared to 15 (13.2 %) on the waiting list (OR 3.4, 95 % CI: 1.7 to 6.8). Thus, group-delivered CBT-I reduced insomnia severity at 3-months follow-up for adults with insomnia. Group-delivered CBT-I offered at Healthy Life Centres is a suitable low-threshold treatment for insomnia in primary care.

Pragmatic Clinical Trials in Neurology

The need for pragmatic clinical trials evaluating therapeutic interventions in patients with neurological disease is continually increasing due to availability of multiple therapeutic interventions (comparative effectiveness), multifaceted approaches (multiple concurrent synergistic therapeutic interventions), and gaps in trial-specific and real-world population outcomes. Several designs for pragmatic trials are available, including individual randomized trials with pragmatic characteristics, cluster-randomized and non-randomized trials, and observational prospective cohort studies. Cluster trials may have parallel cluster and crossover (unidirectional, bidirectional, and alternating crossover) designs. There are unique aspects of consenting and data collection leveraging existing registries, electronic health records (EHRs), and claims data that make pragmatic trials most suited to study the effectiveness of therapeutic interventions in patients with neurological diseases in real-world settings. ANN NEUROL 2025;97:1022-1037.

Participation in a home visiting program predicted maternal but not child vocabulary diversity: A pragmatic randomized trial in Brazil

The Criança Feliz (Happy Child) parenting program is a home visiting intervention serving over a million low-income Brazilian families. The current study assessed its longitudinal associations with maternal and child speech and gestures in a subsample (n = 145) from the program's impact evaluation research. We performed a between-participants pragmatic randomized trial. Mothers (79.7% Black) and children (17-25 months of age; 50.3% female) were randomly assigned to control (n = 73) and intervention (n = 72) groups. One year later, mother-child pairs were recorded playing at home, and the videos were transcribed and analyzed for speech (quantity, vocabulary diversity, sentence complexity, and number of questions) and gestures (quantity). Intention-to-treat analysis revealed that the intervention was associated with the mother's vocabulary diversity (d = .35) regardless of schooling level. No direct or indirect (via maternal speech) associations were observed with the child's speech or gestures. This preliminary evidence suggests that participation in the Criança Feliz program is related to mothers' vocabulary diversity but not to children's speech or gesture measures. The program could focus on maternal gestures, questions, and book reading (complexity feature). Future research evaluating the impact of the program on language outcomes should include pretesting and child follow-up assessments.

Alignment between the research question, design, and terminology is required in manual therapy trials: a methodological study

OBJECTIVES

The study aimed to assess the design, reporting, and risk of bias in effectiveness trials (ETs) in manual therapy (MT), comparing pragmatic with nonpragmatic trials and trials with and without placebo controls.

STUDY DESIGN AND SETTING

We searched MEDLINE and the Cochrane Central Register of Controlled Trials for randomized controlled trials with the term "effectiveness" in the title or abstract in the field of MT from inception to January 2024. Two independent reviewers extracted data on specific study characteristics, their reporting, and risk of bias and assessed them using the PRagmatic Explanatory Continuum Indicatory Summary-2 tool (PRECIS-2). Descriptive analysis using frequencies and percentages and a relation analysis between PRECIS-2 scores and specific study characteristics were performed.

RESULTS

Of the 113 trials, 39 were self-labeled as pragmatic, 39 used usual care or other interventions, and 35 used placebo controls. ETs have increased in recent years. They are moderately pragmatic, whether they are self-described as pragmatic or not, and whether they use a placebo control group or not. Despite their aim to resemble clinical practice, the pragmatic features of these trials are often unclear. Pragmatic features are common in trials' eligibility, recruitment, and outcome domains, but intervention and setting are rated as very explanatory. Compared to self-labeled pragmatic trials, "effectiveness" trials are less likely to follow reporting guidelines.

CONCLUSION

The term effectiveness is used in MT trials independently of its pragmatic connotations. Using a placebo or active control does not modify the pragmatic attitude of the ETs.

Did a digital quality of life (QOL) assessment and practice support system in home health care improve the QOL of older adults living with life-limiting conditions and of their family caregivers? A mixed-methods pragmatic randomized controlled trial

We aimed to improve the quality of life (QOL) of homecare patients (≥ 55 years of age) who had chronic life-limiting conditions and that of their family caregivers by making QOL assessment data available via a digital QOL and practice support system (QPSS). We hypothesized that access to QPSS data in home health care would result in improved QOL for patients or their family caregivers. We further sought to understand how to integrate the use of QOL information into home health care. Our mixed-methods study, including a pragmatic randomized controlled trial (PrCT; registered at ClinicalTrials.gov #NCT02940951), was conducted with nine home healthcare teams in Canadian urban areas. The qualitative research included focus groups and interviews with home healthcare teams (N = 118) to determine how to integrate the QPSS into their practice. Participating homecare patients were assigned to an intervention group (N = 166), where home healthcare teams had access to patients' and their family caregivers' QOL data via the QPSS, or a usual care group (N = 165). Where possible, one family caregiver per patient was recruited (intervention N = 62; usual care N = 51). Primary outcomes, measured every two months for one year, were patients' and family caregivers' QOL trajectories. Longitudinal structural equation models were used to compare the trajectories. The home healthcare teams preferred to have QOL scores presented as tables and graphs, with family caregivers' data linked to each patient. Despite the enthusiasm expressed by the home healthcare teams, and efforts to satisfy their preferences, they infrequently accessed the QOL information. While we observed substantial individual-level variability in patients' and family caregivers' QOL trajectories, the average trajectories for the PrCT groups were similar. Making QOL assessment data available via a digital platform may not be sufficient to achieve measurable improvements for patients and family caregivers.

Finding the balance between rigour and relevance: implementing adaptations to the implementation of a pragmatic randomised controlled trial of a two-way texting intervention for voluntary medical male circumcision in South Africa

OBJECTIVES

To document adaptations that were made to the implementation of the two-way texting (2wT) randomised controlled trial (RCT) for voluntary medical male circumcision (VMMC) in South Africa and to provide a nuanced discussion on the differences between adaptations and fidelity in this context.

DESIGN

We conducted a qualitative study using the Framework for Reporting Adaptations and Modifications in Evidence-based Implementation Strategies (FRAME-IS) to examine 2wT adaptations. We reported adaptations to the 2wT intervention using two steps. First, we categorised adaptations in a shared study-specific Google Docs that documented participant engagement with the 2wT system, tracked daily RCT implementation notes, reported software bugs and noted reminder emails about adaptations for the research team. Second, we conducted a qualitative assessment of the influence of adaptations on project outcomes via 10 periodic reflection meetings with VMMC implementers. Reflection documentation included notes from field observations, meeting minutes and informal partner check-ins to complete adaptation documentation. Using the FRAME-IS as a codebook, adaptations were categorised.

SETTING

The RCT was conducted in rural and urban VMMC clinics in the North West and Gauteng districts of South Africa.

PARTICIPANTS

Implementation scientists and VMMC implementers who implemented the 2wT pragmatic randomised controlled trial (pRCT) were participants for the adaptation study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was the adaptations that were made during the implementation of the 2wT pRCT. The secondary outcome measures were fidelity and rigour of implementing adaptations to the 2wT pRCT.

RESULTS

Between June 2021 and February 2022, 13 adaptations were identified in three phases during the implementation of the 2wT pRCT. The first phase of adaptations aimed to augment study recruitment, including conducting weekend VMMC recruitment camps, using mobile outreach services in the rural site, adding two urban sites to increase recruitment, using weekly WhatsApp calls for updates with all implementing teams, using virtual meetings to implement the 2wT strategy remotely during COVID-19 restrictions and allocating one clinician to work outside of normal working hours. The second phase of adaptations further enhanced enrolments, including adding two local language translations in the usability survey for 2wT men and contributing a portion towards the salary of the implementing staff by the research partner. The third phase included the exclusion of two rural clinics as recruitment sites due to inconsistent mobile phone networks, adding another layer of data quality checks to ensure data quality, training non-clinical counsellors to help with enrolling clients, retraining of staff in the rural site with high staff turnover and using both primary and alternative phone numbers for enrolment to reduce loss to follow-up.

CONCLUSIONS

This study made adaptations to the 2wT pRCT without compromising the fidelity of the study. The 2wT pRCT balances rigour (fidelity) and relevance (adaptation). Adaptations should not be confined by rigour but should also not go unchallenged or unverified. We conclude that fidelity can be maintained with adaptations that are implemented to close the gap between research in the laboratory and practice.

TRIAL REGISTRATION NUMBER

The trial from which this study was conducted, 'Expanding and Scaling Two-way Texting to Reduce Unnecessary Follow-Up and Improve Adverse Event Identification Among Voluntary Medical Male Circumcision (VMMC) Participants in the Republic of South Africa', was registered at ClinicalTrials.gov (ID: NCT04327271) on 31 March 2020.

Early initiated noradrenaline versus fluid therapy for hypotension and shock in the emergency department (VASOSHOCK): a protocol for a pragmatic, multi-center, superiority, randomized controlled trial

BACKGROUND

Shock is a condition with high mortality even with early intervention and treatment. Usual care for shock and hypotension in the Emergency Department (ED) is intravenous fluid resuscitation which can lead to fluid overload and other complications. When fluid therapy fails or risk of complications are high, the next treatment step is the use of vasopressors for stabilisation. Noradrenaline therapy for hypotension and shock are commonly used in ED's outside Scandinavia, but the evidence on the optimal initiation time is sparse. The lack of noradrenaline therapy in Scandinavia provides a unique environment to investigate the possible implications of early initiation. The aim of this trial is to investigate whether the use of early initiated noradrenaline compared to ED fluid therapy can improve blood pressure goals and by that, reduce the need for ICU admittance.

METHODS

This protocol describes a pragmatic, multi-center, superiority randomized controlled trial, randomizing patients with hypotension to intervention or control. Eligible patients are ≥ 18-year-old who have received at least 500 ml intravenous fluids (including prehospital administration), and without suspected cardiogenic, haemorrhagic, anaphylactic, or neurogenic causes, or require direct ICU admittance due to non-hemodynamic severe organ failure. The intervention group receives noradrenaline initiated at 0.05 mcg/kg/min with a maximum of 0.15 mcg/kg/min through a peripheral venous catheter for up to 24 h. The control group receives usual care. Treatment is targeted for a systolic blood pressure ≥ 100 mmHg, a mean arterial pressure ≥ 65 mmHg or a clinician defined blood pressure target. We require a sample size of 320 patients to show a significant difference in proportion of patients achieving shock control within 90 min (primary endpoint). Key secondary outcomes include ICU free days alive within 30-days and 30-day all-cause mortality.

DISCUSSION

Previous prospective randomized trials on early peripheral noradrenaline treatment for shock are sparse and are investigated in settings where noradrenaline use is already usual care. Since noradrenaline are not used as standard treatment for shock in Scandinavian EDs, this provides a unique opportunity not only to investigate the early initiation of noradrenaline for shock, but also comparing it directly to ED fluid only approach.

TRIAL REGISTRATION

EU CT ID 2023-504584-16-00.

CLINICALTRIALS

gov NCT05931601. URL: https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05931601.

Effectiveness of negative-pressure wound therapy with instillation compared to standard negative-pressure wound therapy and traditional gauze layer dressing for the treatment of acute traumatic wounds: A randomized controlled trial

BACKGROUND

Acute traumatic wounds often require prolonged healing time and hospitalization. Negative-pressure wound therapy with instillation and dwell time (NPWTi-d) has demonstrated effectiveness in accelerating patient healing over traditional NPWT, and its benefits are well established in the treatment of chronic infected wounds. However, randomized studies examining the use of NPWTi-d in acute traumatic wounds are scarce. This study aimed to examine the effectiveness of NPWTi-d compared to traditional gauze layer dressing and standard NPWT.

METHODS

This single-center, randomized, pragmatic, controlled clinical trial included 120 adult patients with acute traumatic wounds from traffic accidents randomized to NPWTi-d (n = 39), NPWT (n = 41), and gauze dressing (n = 40). Following surgical debridement of the wound bed, all patients underwent definitive wound closure with delayed primary closure, skin grafting, or surgical flaps. The primary outcomes were wound closure time, number of surgical procedures, and hospital length of stay. The secondary outcomes were primary closure type, amputations, complications, and death.

RESULTS

Wound closure time was significantly lower in patients with NPWTi-d compared to patients with NPWT and gauze dressing (6.1 vs. 10 vs. 11.7 days, respectively; p < 0.001). Patients with NPWTi-d had fewer surgical procedures than patients with NPWT and gauze dressing (3.0 vs. 3.5 vs. 6.2, respectively; p < 0.001). No significant differences in length of stay were observed among the groups.

CONCLUSIONS

In this study, patients with acute traumatic wounds who received NPWTi-d experienced shorter wound closure time and fewer surgical procedures than patients who received NPWT or gauze dressing.

CLINICAL TRIAL REGISTRATION

The current study is registered on the Brazilian Clinical Trials Registry (ReBec) platform under the name Comparison between Traditional Dressing, V.A.C. Dressing and V.A.C. Dressing with Instillation in Complex Wounds, ID nº RBR-658g535 at https://ensaiosclinicos.gov.br/rg/RBR-658g535.

Phone call for diabetic people: protocol for a pragmatic, type 1 effectiveness-implementation hybrid clinical trial

OBJECTIVE

To describe an implementation study protocol for an intervention based on educational guidelines focused on seven self-care behaviors, through phone calls to individuals with type 2 diabetes.

METHOD

We will conduct a hybrid type 1 effectiveness-implementation pragmatic randomized clinical trial, with 198 individuals with type 2 diabetes on insulin therapy, from the Glycemic Self-Monitoring Program of two Primary Health Care in the city of São Paulo and three in Campinas, located in the state of Sao Paulo. Patients will be allocated in a 1:1 ratio to either the intervention or control group. Both groups will receive standard care, with the intervention group also receiving a phone call. During the call, nurses will provide guidance based on seven self-care behaviors, known as The ADCES7 Self-Care Behaviors™. Evaluations will happen at the baseline, and after 3- and 6-months post initiation of the trial. Glycemic levels and adherence to self-care behaviors will be compared before and after the intervention using multiple linear regression models. Through interviews with participants from the intervention group, implementation determinants based on the Capability, Opportunity, Motivation-Behavior (COM-B) model, and implementation outcomes feasibility, acceptability, and appropriateness will be evaluated.

EXPECTED OUTCOMES

We will evaluate the effectiveness of an intervention while exploring contextual conditions for its implementation in clinical practice of Primary Health Care. This study will provide preliminary evidence on the effectiveness of educational guidance through nurse-led telephone calls, as well as implementation determinants and outcomes in the clinical practice of Primary Health Care. Its results are important for expanding this assistance in locations where nursing consultation for people with diabetes is absent, hindered, or restricted. Study is registered on the ReBEC platform.

Comments, suggestions, and criticisms of the Pragmatic Explanatory Continuum Indicator Summary-2 design tool: a citation analysis

INTRODUCTION

The pragmatic explanatory continuum indicator summary (PRECIS) tool, initially published in 2009 and revised in 2015, was created to assist trialists to align their design choices with the intended purpose of their randomised controlled trial (RCT): either to guide real-world decisions between alternative interventions (pragmatic) or to test hypotheses about intervention mechanisms by minimising sources of variation (explanatory). There have been many comments, suggestions, and criticisms of PRECIS-2. This summary will be used to facilitate the development of to the next revision, which is PRECIS-3.

METHODS

We used Web of Science to identify all publication types citing PRECIS-2, published between May 2015 and July 2023. Citations were eligible if they contained 'substantive' suggestions, comments, or criticism of the PRECIS-2 tool. We defined 'substantive' as comments explicitly referencing at least one PRECIS-2 domain or a concept directly linked to an existing or newly proposed domain. Two reviewers independently extracted comments, suggestions, and criticisms, noting their implications for the update. These were discussed among authors to achieve consensus on the interpretation of each comment and its implications for PRECIS-3.

RESULTS

The search yielded 885 publications, and after full-text review, 89 articles met the inclusion criteria. Comments pertained to new domains, changes in existing domains, or were relevant across several or all domains. Proposed new domains included assessment of the comparator arm and a domain to describe blinding. There were concerns about scoring eligibility and recruitment domains for cluster trials. Suggested areas for improvement across domains included the need for more scoring guidance for explanatory design choices.

DISCUSSION

Published comments recognise PRECIS-2's success in aiding trialists with pragmatic or explanatory design choices. Enhancing its implementation and widespread use will involve adding new domains, refining domain definitions, and addressing overall tool issues. This citation review offers valuable user feedback, pivotal for shaping the upcoming version of the PRECIS tool, PRECIS-3.

Perceptions of indirect treatment comparisons as an evidence base in oncology decision-making: results of an international survey of health technology assessment and payer decision-makers

Aim: Health technology assessment (HTA) and payer organizations are often faced with early decision-making in oncology. To design and conduct robust indirect treatment comparisons (ITCs), it is important to better understand HTA and payer decision-maker perceptions of ITCs. Here we aim to describe what individuals with HTA and payer experience see as the acceptability of ITCs for HTA and payer organization coverage and reimbursement decision-making. Materials & methods: This survey included 30 current and former HTA and payer decision-makers from five countries: Australia, France, Germany, the UK (n = 5 each) and the US (n = 10). Main outcomes included the ratings of acceptance of ITCs and the presence of well-defined methodological guidance for ITCs. Results: ITCs are generally accepted by participants in Australia and the UK but are more likely evaluated on a case-by-case basis in France, Germany and the US. Four of five participants in Germany and the UK, two of five in Australia and one of five in France reported that well-defined and prescribed criteria regarding the use of ITCs were in place. Conclusion: There is a need for harmonization of methods used to assess ITCs by HTA and payers, especially in the rapidly evolving treatment landscape in oncology.

A call for academic pragmatic clinical trials to address open questions in migraine prevention

The migraine treatment landscape has seen significant advancements in recent years, including the introduction of novel preventive agents specifically targeting the disease. These new treatments offer improved efficacy and tolerability, potentially addressing the issue of poor treatment adherence commonly observed with conventional preventatives. In this context, pragmatic trials emerge as a critical tool for advancing migraine care, offering a real-world approach to evaluating open clinical questions at the same time as avoiding the biases of real-world observational evidence. By prioritizing external validity and patient-centered outcomes, pragmatic trials provide valuable insights into the advantages of new treatments in improving migraine care. Possible applications of pragmatic trials in migraine research include head-to-head comparisons, evaluation of combination therapies, assessment of treatment sequences and switch, testing the added value of patient-reported outcomes, investigation of long-term effectiveness and on optimal treatment duration, understanding the role of preventive treatments in altering the course of migraine and preventing progression, and cost-effectiveness analyses. Pragmatic trials allow for the assessment of interventions in diverse patient populations and healthcare settings, enhancing the generalizability of findings and informing evidence-based clinical practice. As such, pragmatic trials represent an excellent tool to bridge the gap between placebo-controlled trials and real-world practice and should receive consideration for funding, especially by public institutions such as universities, national health services, and charities.

Impact of the modified curricula on periodontal instrumentation skills development during the COVID-19 pandemic from 2020 to 2023

OBJECTIVES

This study aimed to evaluate the impact of curriculum modifications on periodontal instrumentation skills development among classes of 2021, 2022, and 2023 during the COVID-19 pandemic.

METHODS

The pandemic began and affected the three classes at different stages of their studies. Onsite simulation-based learning (SBL) was employed for the classes of 2021 and 2022; remote SBL was adopted for the class of 2023. Modified clinical education, due to social distancing guidelines, impacted the class of 2021 significantly and the class of 2022 to a lesser extent. A multiple linear regression model was built to examine the association between the fourth-year patient-based scaling competency examination scores and selected predictors.

RESULTS

The classes of 2021 and 2023 showed consistent performances over time, while the class of 2022 exhibited significant variation exhibiting the lowest performance at the second-year practical examination. While the clinical experience of the class of 2021 was significantly less than that of the classes of 2022 and 2023, the fourth-year competency examination scores did not differ across the three classes. The clinic points (p = 0.014) significantly affected the fourth-year competency examination score while student gender (p = 0.18), the first-year (p = 0.736), and second-year (p = 0.198) practical examination scores showed no correlations.

CONCLUSION

Based on student performance in the fourth-year scaling competency examination, the curriculum modifications due to the COVID pandemic did not affect student learning outcomes. Clinical experience was the most influential determinant of skill development in periodontal instrumentation.

Prediabetes and cardiovascular risk factors: the effectiveness of a guided self-determination counselling approach in primary health care, a randomized controlled trial

BACKGROUND

Identify individuals who are at risk of Type 2 diabetes, who also are at a greater risk of developing cardiovascular disease is important. The rapid worldwide increase in diabetes prevalence call for Primary Health Care to find feasible prevention strategies, to reduce patient risk factors and promote lifestyle changes. Aim of this randomized controlled trial was to investigate how a nurse-lead Guided Self-Determination counselling approach can assist people at risk of type 2 diabetes to lower their coronary heart disease risk.

METHODS

In this randomized controlled study, 81 people at risk of developing type 2 diabetes were assigned into an intervention group (n = 39) receiving Guided Self-Determination counselling from Primary Health Care nurses over three months and a control group (n = 42) that received a diet leaflet only. Measurements included the Finnish Diabetes Risk Score questionnaire and biological measurements of Hemoglobin A1c protein, Body Mass Index, fasting blood glucose, Blood pressure, Cholesterol, High-density lipoprotein, and triglycerides, at baseline (time1), 6 (time2) and 9 months (time 3).

RESULTS

A total of 56 participants, equal number in intervention and control groups, completed all measurements. A significant difference between the intervention and control groups, in coronary heart disease risk was not found at 6 nor 9-months. However, within-group data demonstrated that 55.4% of the participants had lower coronary heart disease risk in the next ten years at the 9-month measurement. Indicating an overall 18% relative risk reduction of coronary heart disease risk by participating in the trial, with the number needed to treat for one to lower their risk to be nine. Within the intervention group a significant difference was found between time 1 and 3 in lower body mass index (p = 0.046), hemoglobin A1c level (p = 0.018) and diastolic blood pressure (p = 0.03).

CONCLUSIONS

Although unable to show significant group differences in change of coronary heart disease risk by this 12-weeks intervention, the process of regular measurements and the guided self-determination counselling seem to be beneficial for within-group measures and the overall reduction of coronary heart disease risk factors.

TRIAL REGISTRATION

This study is a part of the registered study 'Effectiveness of Nurse-coordinated Follow-Up Programme in Primary Care for People at Risk of T2DM' at www.

CLINICALTRIALS

gov (NCT04688359) (accessed on 30 December 2020).

Methods for pragmatic randomized clinical trials of pain therapies: IMMPACT statement

ABSTRACT

Pragmatic, randomized, controlled trials hold the potential to directly inform clinical decision making and health policy regarding the treatment of people experiencing pain. Pragmatic trials are designed to replicate or are embedded within routine clinical care and are increasingly valued to bridge the gap between trial research and clinical practice, especially in multidimensional conditions, such as pain and in nonpharmacological intervention research. To maximize the potential of pragmatic trials in pain research, the careful consideration of each methodological decision is required. Trials aligned with routine practice pose several challenges, such as determining and enrolling appropriate study participants, deciding on the appropriate level of flexibility in treatment delivery, integrating information on concomitant treatments and adherence, and choosing comparator conditions and outcome measures. Ensuring data quality in real-world clinical settings is another challenging goal. Furthermore, current trials in the field would benefit from analysis methods that allow for a differentiated understanding of effects across patient subgroups and improved reporting of methods and context, which is required to assess the generalizability of findings. At the same time, a range of novel methodological approaches provide opportunities for enhanced efficiency and relevance of pragmatic trials to stakeholders and clinical decision making. In this study, best-practice considerations for these and other concerns in pragmatic trials of pain treatments are offered and a number of promising solutions discussed. The basis of these recommendations was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) meeting organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks.

Challenges and Alternatives to Evaluation Methods and Regulation Approaches for Medical Apps as Mobile Medical Devices: International and Multidisciplinary Focus Group Discussion

BACKGROUND

The rapid proliferation of medical apps has transformed the health care landscape by giving patients and health care providers unprecedented access to personalized health information and services. However, concerns regarding the effectiveness and safety of medical apps have raised questions regarding the efficacy of randomized controlled trials (RCTs) in the evaluation of such apps and as a requirement for their regulation as mobile medical devices.

OBJECTIVE

This study aims to address this issue by investigating alternative methods, apart from RCTs, for evaluating and regulating medical apps.

METHODS

Using a qualitative approach, a focus group study with 46 international and multidisciplinary public health experts was conducted at the 17th World Congress on Public Health in May 2023 in Rome, Italy. The group was split into 3 subgroups to gather in-depth insights into alternative approaches for evaluating and regulating medical apps. We conducted a policy analysis on the current regulation of medical apps as mobile medical devices for the 4 most represented countries in the workshop: Italy, Germany, Canada, and Australia. We developed a logic model that combines the evaluation and regulation domains on the basis of these findings.

RESULTS

The focus group discussions explored the strengths and limitations of the current evaluation and regulation methods and identified potential alternatives that could enhance the quality and safety of medical apps. Although RCTs were only explicitly mentioned in the German regulatory system as one of many options, an analysis of chosen evaluation methods for German apps on prescription pointed toward a "scientific reflex" where RCTs are always the chosen evaluation method. However, this method has substantial limitations when used to evaluate digital interventions such as medical apps. Comparable results were observed during the focus group discussions, where participants expressed similar experiences with their own evaluation approaches. In addition, the participants highlighted numerous alternatives to RCTs. These alternatives can be used at different points during the life cycle of a digital intervention to assess its efficacy and potential harm to users.

CONCLUSIONS

It is crucial to recognize that unlike analog tools, digital interventions constantly evolve, posing challenges to inflexible evaluation methods such as RCTs. Potential risks include high dropout rates, decreased adherence, and nonsignificant results. However, existing regulations do not explicitly advocate for other evaluation methodologies. Our research highlighted the necessity of overcoming the gap between regulatory demands to demonstrate safety and efficacy of medical apps and evolving scientific practices, ensuring that digital health innovation is evaluated and regulated in a way that considers the unique characteristics of mobile medical devices.

Pragmatic randomized controlled trial comparing a complex telemedicine-based intervention with usual care in patients with chronic conditions

This study evaluates a complex telemedicine-based intervention targeting patients with chronic health problems. Computer tablets and home telemonitoring devices are used by patients to report point-of-care measurements, e.g., blood pressure, blood glucose or oxygen saturation, and to answer health-related questions at a follow-up center. We designed a pragmatic randomized controlled trial to compare the telemedicine-based intervention with usual care in six local centers in Norway. The study outcomes included health-related quality of life (HRQoL) based on the EuroQol questionnaire (EQ-5D-5L), patient experiences, and utilization of healthcare. We also conducted a cost-benefit analysis to inform policy implementation, as well as a process evaluation (reported elsewhere). We used mixed methods to analyze data collected during the trial (health data, survey data and interviews with patients and health personnel) as well as data from national health registers. 735 patients were included during the period from February 2019 to June 2020. One year after inclusion, the effects on the use of healthcare services were mixed. The proportion of patients receiving home-based care services declined, but the number of GP contacts increased in the intervention group compared to the control group. Participants in the intervention group experienced improved HRQoL compared to the control group and were more satisfied with the follow-up of their health. The cost-benefit of the intervention depends largely on the design of the service and the value society places on improved safety and self-efficacy.

Effects of a self-guided digital mental health self-help intervention for Syrian refugees in Egypt: A pragmatic randomized controlled trial

BACKGROUND

Digital mental health interventions for smartphones, such as the World Health Organization (WHO) Step-by-Step (SbS) program, are potentially scalable solutions to improve access to mental health and psychosocial support in refugee populations. Our study objective was to evaluate the effectiveness of SbS as self-guided intervention with optional message-based contact-on-demand (COD) support on reducing psychological distress, functional impairment, symptoms of posttraumatic stress disorder (PTSD), and self-identified problems in a sample of Syrian refugees residing in Egypt.

METHODS AND FINDINGS

We conducted a 2-arm pragmatic randomized controlled trial. A total of 538 Syrians residing in Egypt with elevated levels of psychological distress (Kessler Psychological Distress Scale; K10 > 15) and reduced psychosocial functioning (WHODAS 2.0 > 16) were randomized into SbS + CAU (N = 266) or CAU only (N = 272). Primary outcomes were psychological distress (Hopkins Symptom Checklist 25) and impaired functioning (WHO Disability Assessment Schedule 2.0) at 3-month follow-up. Secondary outcomes were symptoms of PTSD (PTSD Checklist for DSM-5 short form, PCL-5 short) and self-identified problems (Psychological Outcomes Profiles Scale, PSYCHLOPS). Intention-to-treat (ITT) analyses showed significant but small effects of condition on psychological distress (mean difference: -0.15; 95% CI: -0.28, -0.02; p = .02) and functioning (mean difference: -2.04; 95% CI: -3.87, -0.22; p = .02) at 3-month follow-up. There were no significant differences between groups on symptoms of PTSD and self-identified problems. Remission rates did not differ between conditions on any of the outcomes. COD was used by 9.4% of participants for a median of 1 contact per person. The main limitations are high intervention dropout and low utilization of COD support.

CONCLUSIONS

The trial provides a real-world implementation case, showing small positive effects of a digital, potentially scalable and self-guided mental health intervention for Syrian refugees in Egypt in reducing psychological distress and improving overall functioning. Further user-centered adaptations are required to improve adherence and effectiveness while maintaining scalability.

TRIAL REGISTRATION

German Register for Clinical Studies DRKS00023505.

The implementation of EMI-Heart, a family-tailored early motor intervention in infants with complex congenital heart disease, in practice: a feasibility RCT

BACKGROUND

Children with congenital heart disease (CHD) who undergo open-heart surgery are at risk of developmental impairment, including motor delay, which contributes to parental concerns. Additionally, parents experience prolonged stress associated with their child's disease. There is a lack of early motor interventions in infants with CHD accounting for parental burdens. We developed a family-tailored early motor intervention (EMI-Heart), aiming to promote motor development in infants with CHD and family well-being. The primary aim was to evaluate the feasibility of the study design and the intervention. The secondary aim was to evaluate differences between the intervention and the control group in motor outcomes and family well-being at baseline (3-5 months), post-treatment (6-8 months), and at follow-up (12 months).

METHOD

In this single-centre feasibility randomized control trial (RCT), infants with CHD after open-heart surgery without genetic or major neurological comorbidities were randomly allocated to EMI-Heart or the control group (standard of care). EMI-Heart's key elements promote postural functional activities and encourage parental sensitivity to infants' motor and behaviour cues. Infants assigned to EMI-Heart received nine sessions of early motor intervention at home, in the hospital, and online for a duration of 3 months by a paediatric physiotherapist. We performed descriptive statistics for feasibility and secondary outcomes.

RESULTS

The recruitment rate was 59% (10/17), all participating families completed the study (10/10), and the intervention duration was 3.9 months (± 0.54), including nine intervention sessions per family. Median acceptability to parents was 3.9 (1 = not agree-4 = totally agree, Likert scale). The paediatric physiotherapist considered the intervention as feasible. The comparison of motor outcomes did not show differences between groups. However, we detected improved reliable change scores in family well-being outcomes for families of the intervention group compared to the controls.

CONCLUSIONS

Our research indicates that EMI-Heart is a feasible intervention for infants with CHD after open-heart surgery. The intervention was highly acceptable both to parents and to the paediatric physiotherapist. Online treatment sessions offer a valuable alternative to home and hospital visits. This feasibility RCT provides a foundation for a future full trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCTT04666857. Registered 23.11.2020.

Harnessing health information technology to promote equitable care for patients with limited English proficiency and complex care needs

BACKGROUND

Patients with language barriers encounter healthcare disparities, which may be alleviated by leveraging interpreter skills to reduce cultural, language, and literacy barriers through improved bidirectional communication. Evidence supports the use of in-person interpreters, especially for interactions involving patients with complex care needs. Unfortunately, due to interpreter shortages and clinician underuse of interpreters, patients with language barriers frequently do not get the language services they need or are entitled to. Health information technologies (HIT), including artificial intelligence (AI), have the potential to streamline processes, prompt clinicians to utilize in-person interpreters, and support prioritization.

METHODS

From May 1, 2023, to June 21, 2024, a single-center stepped wedge cluster randomized trial will be conducted within 35 units of Saint Marys Hospital & Methodist Hospital at Mayo Clinic in Rochester, Minnesota. The units include medical, surgical, trauma, and mixed ICUs and hospital floors that admit acute medical and surgical care patients as well as the emergency department (ED). The transitions between study phases will be initiated at 60-day intervals resulting in a 12-month study period. Units in the control group will receive standard care and rely on clinician initiative to request interpreter services. In the intervention group, the study team will generate a daily list of adult inpatients with language barriers, order the list based on their complexity scores (from highest to lowest), and share it with interpreter services, who will send a secure chat message to the bedside nurse. This engagement will be triggered by a predictive machine-learning algorithm based on a palliative care score, supplemented by other predictors of complexity including length of stay and level of care as well as procedures, events, and clinical notes.

DISCUSSION

This pragmatic clinical trial approach will integrate a predictive machine-learning algorithm into a workflow process and evaluate the effectiveness of the intervention. We will compare the use of in-person interpreters and time to first interpreter use between the control and intervention groups.

TRIAL REGISTRATION

NCT05860777. May 16, 2023.

Two-Year Outcomes of Umbilical Cord Milking in Nonvigorous Infants: A Secondary Analysis of the MINVI Randomized Clinical Trial

Importance

Compared with early cord clamping (ECC), umbilical cord milking (UCM) reduces delivery room cardiorespiratory support, hypoxic-ischemic encephalopathy, and therapeutic hypothermia in nonvigorous near-term and full-term infants. However, UCM postdischarge outcomes are not known.

Objective

To determine the 2-year outcomes of children randomized to UCM or ECC at birth in the Milking in Nonvigorous Infants (MINVI) trial.

Design, Setting, and Participants

A secondary analysis to evaluate longer-term outcomes of a cluster-randomized crossover trial was conducted from January 9, 2021, to September 25, 2023. The primary trial took place in 10 medical centers in the US, Canada, and Poland from January 5, 2019, to June 1, 2021, and hypothesized that UCM would reduce admission to the neonatal intensive care unit compared with ECC; follow-up concluded September 26, 2023. The population included near-term and full-term infants aged 35 to 42 weeks' gestation at birth who were nonvigorous; families provided consent to complete developmental screening questionnaires through age 2 years.

Intervention

UCM and ECC.

Main Outcomes and Measures

Ages and Stages Questionnaire, 3rd Edition (ASQ-3) and Modified Checklist for Autism in Toddlers, Revised/Follow-Up (M-CHAT-R/F) questionnaires at ages 22 to 26 months. Intention-to-treat analysis and per-protocol analyses were used.

Results

Among 1730 newborns from the primary trial, long-term outcomes were evaluated in 971 children (81%) who had ASQ-3 scores available at 2 years or died before age 2 years and 927 children (77%) who had M-CHAT-R/F scores or died before age 2 years. Maternal and neonatal characteristics by treatment group were similar, with median birth gestational age of 39 (IQR, 38-40) weeks in both groups; 224 infants (45%) in the UCM group and 201 (43%) in the ECC group were female. The median ASQ-3 total scores were similar (UCM: 255 [IQR, 225-280] vs ECC: 255 [IQR, 230-280]; P = .87), with no significant differences in the ASQ-3 subdomains. Medium- to high-risk M-CHAT-R/F scores were also similar (UCM, 9% [45 of 486] vs ECC, 8% [37 of 441]; P = .86).

Conclusions and Relevance

In this secondary analysis of a randomized clinical trial among late near-term and full-term infants who were nonvigorous at birth, ASQ-3 scores at age 2 years were not significantly different between the UCM and ECC groups. Combined with previously reported important short-term benefits, this follow-up study suggests UCM is a feasible, no-cost intervention without longer-term neurodevelopmental risks of cord milking in nonvigorous near-term and term newborns.

Trial Registration

ClinicalTrials.gov Identifier: NCT03631940.

Pragmaticism in Cancer Clinical Trials

Clinical trials are essential for advancing oncology treatment strategies and have contributed significantly to the decline in cancer mortality rates over the past decades. Traditional explanatory trials, focused on establishing intervention efficacy in ideal settings, often lack generalizability and may not reflect real-world patient care scenarios. Furthermore, increasing complexity in cancer clinical trial design has led to challenges such as protocol deviations, slow enrollment leading to lengthened durations of trial, and escalating costs. By contrast, pragmatic trials aim to assess intervention effectiveness in more representative patient populations under routine clinical conditions. Here, we review the principles, methodologies, challenges, and advantages of incorporating pragmatic features (PFs) into cancer clinical trials. We illustrate the application of pragmatic trial designs in oncology and discuss the QUASAR collaborative, TAPUR study, and the ongoing PRAGMATICA-LUNG trial. Although not all oncology trials may be amenable to adopting fully pragmatic designs, integration of PFs when feasible will enhance trial generalizability and real-world applicability. Project Pragmatica and similar initiatives advocate for the integration of real-world practice with clinical trials, fostering a nuanced approach to oncology research that balances efficacy and effectiveness assessments, ultimately with a goal of improving patient outcomes.

Implementation research: a protocol for two three-arm pragmatic randomised controlled trials on continuous glucose monitoring devices in people with type 1 diabetes in South Africa and Kenya

BACKGROUND

Self-monitoring of glucose is an essential component of type 1 diabetes (T1D) management. In recent years, continuous glucose monitoring (CGM) has provided an alternative to daily fingerstick testing for the optimisation of insulin dosing and general glucose management in people with T1D. While studies have been conducted to evaluate the impact of CGM on clinical outcomes in the US, Europe and Australia, there are limited data available for low- and middle-income countries (LMICs) and further empirical evidence is needed to inform policy decision around their use in these countries.

METHODS

This trial was designed as a pragmatic, parallel-group, open-label, multicentre, three-arm, randomised (1:1:1) controlled trial of continuous or periodic CGM device use versus standard of care in people with T1D in South Africa and Kenya. The primary objective of this trial will be to assess the impact of continuous or periodic CGM device use on glycaemic control as measured by change from baseline glycosylated haemoglobin (HbA1c). Additional assessments will include clinical outcomes (glucose variation, time in/below/above range), safety (adverse events, hospitalisations), quality of life (EQ-5D, T1D distress score, Glucose Monitoring Satisfaction Survey for T1D), and health economic measures (incremental cost-effectiveness ratios, quality adjusted life years).

DISCUSSION

This trial aims to address the substantial evidence gap on the impact of CGM device use on clinical outcomes in LMICs, specifically South Africa and Kenya. The trial results will provide evidence to inform policy and treatment decisions in these countries.

TRIAL REGISTRATION

NCT05944731 (Kenya), July 6, 2023; NCT05944718 (South Africa), July 13, 2023.

EORTC 2238 "De-Escalate": a pragmatic trial to revisit intermittent androgen deprivation therapy in the era of new androgen receptor pathway inhibitors

The landscape of treating metastatic prostate cancer has evolved with the addition of Androgen Receptor pathway inhibitor (ARPI) to Androgen Deprivation Therapy (ADT), significantly improving survival rates. However, prolonged use of these therapies introduces notable side effects, prompting a need to revisit intermittent treatment duration. The EORTC 2238 De-Escalate trial is a pragmatic trial seeking to reassess the role of intermittent therapy in patients undergoing maximal androgen blockade (MAB) for metastatic hormone naïve prostate cancer (mHNPC), i.e., the combination of ADT with an ARPI, with the aims of reducing side effects, enhancing Quality of Life (QoL) and optimizing resource usage, while maintaining oncological benefits.

Understanding Decision Making as It Influences Treatment in Thoracolumbar Burst Fractures Without Neurological Deficit: Conceptual Framework and Methodology

STUDY DESIGN

This paper presents a description of a conceptual framework and methodology that is applicable to the manuscripts that comprise this focus issue.

OBJECTIVES

Our goal is to present a conceptual framework which is relied upon to better understand the processes through which surgeons make therapeutic decisions around how to treat thoracolumbar burst fractures (TL) fractures.

METHODS

We will describe the methodology used in the AO Spine TL A3/4 Study prospective observational study and how the radiographs collected for this study were utilized to study the relationships between various variables that factor into surgeon decision making.

RESULTS

With 22 expert spine trauma surgeons analyzing the acute CT scans of 183 patients with TL fractures we were able to perform pairwise analyses, look at reliability and correlations between responses and develop frequency tables, and regression models to assess the relationships and interactions between variables. We also used machine learning to develop decision trees.

CONCLUSIONS

This paper outlines the overall methodological elements that are common to the subsequent papers in this focus issue.

Interobserver Reliability in the Classification of Thoracolumbar Fractures Using the AO Spine TL Injury Classification System Among 22 Clinical Experts in Spine Trauma Care

STUDY DESIGN

Reliability study utilizing 183 injury CT scans by 22 spine trauma experts with assessment of radiographic features, classification of injuries and treatment recommendations.

OBJECTIVES

To assess the reliability of the AOSpine TL Injury Classification System (TLICS) including the categories within the classification and the M1 modifier.

METHODS

Kappa and Intraclass correlation coefficients were produced. Associations of various imaging characteristics (comminution, PLC status) and treatment recommendations were analyzed through regression analysis. Multivariable logistic regression modeling was used for making predictive algorithms.

RESULTS

Reliability of the AO Spine TLICS at differentiating A3 and A4 injuries (N = 71) (K = .466; 95% CI .458 - .474; P < .001) demonstrated moderate agreement. Similarly, the average intraclass correlation coefficient (ICC) amongst A3 and A4 injuries was excellent (ICC = .934; 95% CI .919 - .947; P < .001) and the ICC between individual measures was moderate (ICC = .403; 95% CI .351 - .461; P < .001). The overall agreement on the utilization of the M1 modifier amongst A3 and A4 injuries was fair (K = .161; 95% CI .151 - .171; P < .001). The ICC for PLC status in A3 and A4 injuries averaged across all measures was excellent (ICC = .936; 95% CI .922 - .949; P < .001). The M1 modifier suggests respondents are nearly 40% more confident that the PLC is injured amongst all injuries. The M1 modifier was employed at a higher frequency as injuries were classified higher in the classification system.

CONCLUSIONS

The reliability of surgeons differentiating between A3 and A4 injuries in the AOSpine TLICS is substantial and the utilization of the M1 modifier occurs more frequently with higher grades in the system.

LATTE: Label-efficient incident phenotyping from longitudinal electronic health records

Electronic health record (EHR) data are increasingly used to support real-world evidence studies but are limited by the lack of precise timings of clinical events. Here, we propose a label-efficient incident phenotyping (LATTE) algorithm to accurately annotate the timing of clinical events from longitudinal EHR data. By leveraging the pre-trained semantic embeddings, LATTE selects predictive features and compresses their information into longitudinal visit embeddings through visit attention learning. LATTE models the sequential dependency between the target event and visit embeddings to derive the timings. To improve label efficiency, LATTE constructs longitudinal silver-standard labels from unlabeled patients to perform semi-supervised training. LATTE is evaluated on the onset of type 2 diabetes, heart failure, and relapses of multiple sclerosis. LATTE consistently achieves substantial improvements over benchmark methods while providing high prediction interpretability. The event timings are shown to help discover risk factors of heart failure among patients with rheumatoid arthritis.

Effect of robot for medication management on home care professionals' use of working time in older people's home care: a non-randomized controlled clinical trial

BACKGROUND

Medication management has a key role in the daily tasks of home care professionals delivered to older clients in home care. The aim of this study was to examine the effect of using a robot for medication management on home care professionals´ use of working time.

METHODS

A pragmatic non-randomized controlled clinical trial was conducted. The participants were home care professionals who carried out home care clients' medication management. Home care clients were allocated into intervention groups (IG) and control groups (CG) (n = 64 and 46, respectively) based on whether or not they received the robot. Data were collected using the Working Time Tracking Form prior to and 1 and 2 months after introducing the intervention. The t-test was used to compare the groups at each three timepoints. Analysis of Covariance was used to examine the groups' differences for the total time for medications as the number of visits per day as the covariate.

RESULTS

With robot use, the total amount of home visits decreased by 89.4% and 92.4% after 1 and 2 months of intervention use, respectively, compared to pre-intervention (p < 0.001). The total working time used for medication management considering the number of visits per day decreased from 54.2 min (95% CI 37.4-44.3) to 34.9 min (31.4-38.3), i.e., by slightly over 19 min (p < 0.001) in the IG group. During the follow-up, the total working time used for medication management considering the number of visits per day remained the same in the CG group.

CONCLUSION

Using a robot for medication management had a notable effect on decreasing the use of working time of home care professionals. For health services, decreased use of working time for medication management means that the time saved can be assigned to services that cannot be replaced otherwise. More digital solutions should be developed based on home care clients' and professionals' needs to meet the challenge of the growing number of older people in need of home care and ensure their safety.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05908604 retrospectively registered (18/06/2023).

Rapid Detection of Influenza Outbreaks in Long-Term Care Facilities Reduces Emergency Room Visits and Hospitalization: A Randomized Trial

OBJECTIVES

To assess whether the use of rapid influenza diagnostic tests (RIDTs) for long-term care facility (LTCF) residents with acute respiratory infection is associated with increased antiviral use and decreased health care utilization.

DESIGN

Nonblinded, pragmatic, randomized controlled trial evaluating a 2-part intervention with modified case identification criteria and nursing staff-initiated collection of nasal swab specimen for on-site RIDT.

SETTING AND PARTICIPANTS

Residents of 20 LTCFs in Wisconsin matched by bed capacity and geographic location and then randomized.

METHODS

Primary outcome measures, expressed as events per 1000 resident-weeks, included antiviral treatment courses, antiviral prophylaxis courses, total emergency department (ED) visits, ED visits for respiratory illness, total hospitalizations, hospitalizations for respiratory illness, hospital length of stay, total deaths, and deaths due to respiratory illness over 3 influenza seasons.

RESULTS

Oseltamivir use for prophylaxis was higher at intervention LTCFs [2.6 vs 1.9 courses per 1000 person-weeks; rate ratio (RR) 1.38, 95% CI 1.24-1.54; P < .001]; rates of oseltamivir use for influenza treatment were not different. Rates of total ED visits (7.6 vs 9.8/1000 person-weeks; RR 0.78, 95% CI 0.64-0.92; P = .004), total hospitalizations (8.6 vs 11.0/1000 person-weeks; RR 0.79, 95% CI 0.67-0.93; P = .004), and hospital length of stay (35.6 days vs 55.5 days/1000 person-weeks; RR 0.64, 95% CI 0.0.59-0.69; P < .001) were lower at intervention as compared to control LTCFs. No significant differences were noted for respiratory-related ED visits or hospitalizations or in rates for all-cause or respiratory-associated mortality.

CONCLUSIONS AND IMPLICATIONS

The use of low threshold criteria to trigger nursing staff-initiated testing for influenza with RIDT resulted in increased prophylactic use of oseltamivir. There were significant reductions in the rates of all-cause ED visits (22% decline), hospitalizations (21% decline), and hospital length of stay (36% decline) across 3 combined influenza seasons. No significant differences were noted in respiratory-associated and all-cause deaths between intervention and control sites.

Effectiveness of behavior change interventions for smoking cessation among expectant and new fathers: findings from a systematic review

BACKGROUND

Smoking cessation during pregnancy and the postpartum period by both women and their partners offers multiple health benefits. However, compared to pregnant/postpartum women, their partners are less likely to actively seek smoking cessation services. There is an increased recognition about the importance of tailored approaches to smoking cessation for expectant and new fathers. While Behavior Change Interventions (BCIs) are a promising approach for smoking cessation interventions, evidence on effectiveness exclusively among expectant and new fathers are fragmented and does not allow for many firm conclusions to be drawn.

METHODS

We conducted a systematic review on effectiveness of BCIs on smoking cessation outcomes of expectant and new fathers both through individual and/or couple-based interventions. Peer reviewed articles were identified from eight databases without any date or language restriction.Two independent reviewers screened studies for relevance, assessed methodological quality of relevant studies, and extracted data from studies using a predeveloped data extraction sheet.

RESULTS

We retrieved 1222 studies, of which 39 were considered for full text screening after reviewing the titles and abstracts. An additional eight studies were identified from reviewing the reference list of review articles picked up by the databases search. A total of nine Randomised Control Trials were included in the study. Six studies targeted expectant/new fathers, two targeted couples and one primarily targeted women with an intervention component to men. While the follow-up measurements for men varied across studies, the majority reported biochemically verified quit rates at 6 months. Most of the interventions showed positive effects on cessation outcomes. BCI were heterogenous across studies. Findings are suggestive of gender targeted interventions being more likely to have positive cessation outcomes.

CONCLUSIONS

This systematic review found limited evidence supporting the effectiveness of BCI among expectant and new fathers, although the majority of studies show positive effects of these interventions on smoking cessation outcomes. There remains a need for more research targeted at expectant and new fathers. Further, there is a need to identify how smoking cessation service delivery can better address the needs of (all) gender(s) during pregnancy.

Mandatory vs. optional split-dose bowel preparation for morning colonoscopies: a pragmatic noninferiority randomized controlled trial

BACKGROUND : We compared the effectiveness of optional split-dose bowel preparation (SDBP) with mandatory SDBP for morning colonoscopies in usual clinical practice. METHODS : Adult patients undergoing outpatient early morning (8:00 AM-10:30 PM) and late morning (10:30 AM-12:00 PM) colonoscopies were included. Written bowel preparation instructions were provided based on randomization: one group were instructed to take their bowel preparation (4 L polyethylene glycol solution) as a split dose (mandatory), while the comparator group was allowed the choice of SDBP or single-dose bowel preparation administered entirely on the day before (optional). The primary end point, using noninferiority hypothesis testing with a 5 % margin, was adequate bowel cleanliness measured by the Boston Bowel Preparation Scale (BBPS) and defined by a BBPS score ≥ 6. RESULTS : Among 770 randomized patients with complete data, there were 267 mandatory SDBP and 265 optional SDBP patients for early morning colonoscopies, and 120 mandatory SDBP and 118 optional SDBP patients for late morning colonoscopies. Optional SDBP was inferior to mandatory SDBP, with a lower proportion of adequate BBPS cleanliness for early morning colonoscopies (78.9 % vs. 89.9 %; absolute risk difference [aRD] 11.0 %, 95 %CI 5.9 % to 16.1 %), but was not statistically different for late morning colonoscopies (76.3 % vs. 83.3 %; aRD 7.1 %, 95 %CI -1.5 % to 15.5 %). CONCLUSIONS : Optional SDBP is inferior to mandatory SDBP in providing adequate bowel preparation quality for early morning colonoscopies (8:00 AM-10:30 AM), and probably inferior for late morning colonoscopies (10:30 AM-12:00 PM).

The co-creation, initial piloting, and protocol for a cluster randomised controlled trial of a coach-led positive body image intervention for girls in sport

BACKGROUND

Globally, girls disengage from sports at an earlier age and higher rate than boys. This is, in part, due to the unique body image challenges that girls face, relative to their male peers. Existing intervention efforts that aim to reduce girls' negative body image and movement experiences have proven marginally effective, if not ineffective. This paper outlines the co-creation, initial piloting and protocol for a cluster randomised controlled trial of Body Confident Athletes (BCA); an in-person, coach-led intervention that aims to foster positive body image and sports enjoyment among girls.

METHODS

Following co-creation and an initial pilot, a two-armed cluster randomised controlled trial will assess the immediate (post-intervention) and short-term (1-month and 3-month follow-up) impact of BCA on girls' (N = 1,036; 11-17 years old) body image, sports enjoyment, and affect. Sport organisations will be randomly allocated (1:1) into either an intervention or waitlist control condition. Girls and coaches in the intervention condition will complete three 60-minute sessions over three consecutive weeks. The primary outcome will be the immediate change in girls' body esteem, with secondary outcomes assessing the immediate and short-term changes in girls' body appreciation, self-objectification, attuned self-care, sports enjoyment, and affect.

DISCUSSION

This research is the first to utilise an international multi-stakeholder partnership to co-create and evaluate an intervention that addresses the intersection of girls' body image and sport experiences. The theoretical and methodological considerations of this research have led to a feasible intervention and trial protocol, and if proven effective, BCA may assist in reducing the global gender disparity in sports participation.

TRIAL REGISTRATION NUMBER

NCT05594524 , registered 25^th October 2022.

Telemedicine Support for Primary Care Providers versus Usual Care in Patients with Heart Failure: Protocol of a Pragmatic Cluster Randomised Trial within the Brazilian Heart Insufficiency with Telemedicine (BRAHIT) Study

Heart failure is a prevalent condition and a frequent cause of hospital readmissions and poor quality of life. Teleconsultation support from cardiologists to primary care physicians managing patients with heart failure may improve care, but the effect on patient-relevant outcomes is unclear. We aim to evaluate whether collaboration through a novel teleconsultation platform in the Brazilian Heart Insufficiency with Telemedicine (BRAHIT) project, tested on a previous feasibility study, can improve patient-relevant outcomes. We will conduct a parallel-group, two-arm, cluster-randomised superiority trial with a 1:1 allocation ratio, with primary care practices from Rio de Janeiro as clusters. Physicians from the intervention group practices will receive teleconsultation support from a cardiologist to assist patients discharged from hospitals after admission for heart failure. In contrast, physicians from the control group practices will perform usual care. We will include 10 patients per each of the 80 enrolled practices (n = 800). The primary outcome will be a composite of mortality and hospital admissions after six months. Secondary outcomes will be adverse events, symptoms frequency, quality of life, and primary care physicians' compliance with treatment guidelines. We hypothesise that teleconsulting support will improve patient outcomes.

Evaluating a body image school-based intervention in India: A randomized controlled trial

Body dissatisfaction is highly prevalent among adolescents in low- and middle- income countries, including in India. However, evidence-based interventions are lacking. This study evaluated the efficacy of a school-based mixed-gender body image intervention among adolescents in India. A randomized controlled trial was conducted among 568 (43 % girls) Year 7 students (aged 11-14; 94 % aged 12-13) in six schools in Delhi. Each school was randomly allocated to receive five 45-minute intervention sessions delivered by trained psychologists or a wait-list control condition. The primary outcome of body image and related secondary outcomes were assessed at pre-intervention, post-intervention, and 3-month follow-up. Intention-to-treat linear mixed models analyses showed improvements in body image relative to the control group at post-intervention and 3-month follow-up. Significant improvements were identified at post-intervention for internalization, life disengagement, disordered eating, self-esteem, and negative affect, with effects maintained in nearly all outcomes (girls only - internalization, boys only - life disengagement) at 3-month follow-up. This study presents the first mixed-gender school-based body image intervention in India, which was efficacious in improving urban adolescents' body image, disordered eating, and related outcomes.

Key considerations for choosing a statistical method to deal with incomplete treatment adherence in pragmatic trials

Pragmatic trials offer practical means of obtaining real-world evidence to help improve decision-making in comparative effectiveness settings. Unfortunately, incomplete adherence is a common problem in pragmatic trials. The commonly used methods in randomized control trials often cannot handle the added complexity imposed by incomplete adherence, resulting in biased estimates. Several naive methods and advanced causal inference methods (e.g., inverse probability weighting and instrumental variable-based approaches) have been used in the literature to deal with incomplete adherence. Practitioners and applied researchers are often confused about which method to consider under a given setting. This current work is aimed to review commonly used statistical methods to deal with non-adherence along with their key assumptions, advantages, and limitations, with a particular focus on pragmatic trials. We have listed the applicable settings for these methods and provided a summary of available software. All methods were applied to two hypothetical datasets to demonstrate how these methods perform in a given scenario, along with the R codes. The key considerations include the type of intervention strategy (point treatment settings, where treatment is administered only once versus sustained treatment settings, where treatment has to be continued over time) and availability of data (e.g., the extent of measured or unmeasured covariates that are associated with adherence, dependent confounding impacted by past treatment, and potential violation of assumptions). This study will guide practitioners and applied researchers to use the appropriate statistical method to address incomplete adherence in pragmatic trial settings for both the point and sustained treatment strategies.

Over Half of Clinical Trials of Mobilization and Manipulation for Patients With Low Back Pain May Have Limited Real-World Applicability: A Systematic Review of 132 Clinical Trials

OBJECTIVE

To evaluate the existing body of trials assessing manual therapy for low back pain (LBP) to determine where it falls on the efficacyeffectiveness continuum.

DESIGN

Methodology systematic review.

LITERATURE SEARCH

PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and PEDro (Physiotherapy Evidence Database) were searched for trials published between January 1, 2000, and April 30, 2021.

STUDY SELECTION CRITERIA

We included randomized clinical trials investigating joint mobilization and manipulation for adults with nonspecific LBP that were available in English.

DATA SYNTHESIS

We used the Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool to score included trials across 4 domains: participant characteristics, trial setting, flexibility of intervention(s), and clinical relevance of experimental and comparison intervention(s). Proportions of trials with greater emphasis on efficacy or effectiveness were calculated for each domain.

RESULTS

Of the 132 included trials, a greater proportion emphasized efficacy than effectiveness for domains participant characteristics (50% vs 38%), trial setting (71% vs 20%), and flexibility of intervention(s) (61% vs 25%). The domain clinical relevance of experimental and comparison intervention(s) had lower emphasis on efficacy (41% vs 50%).

CONCLUSION

Most trials investigating manual therapy for LBP lack pragmatism across the RITES domains (ie, they emphasize efficacy). To improve real-world implementation, more research emphasizing effectiveness is needed. This could be accomplished by recruiting from more diverse participant pools, involving multiple centers that reflect common clinical practice settings, involving clinicians with a variety of backgrounds/experience, and allowing flexibility in how interventions are delivered. J Orthop Sports Phys Ther 2022;52(8):532-545. Epub: 19 June 2022. doi:10.2519/jospt.2022.10962.

Development, Testing, and Implementation of the Belgian Patient Reported Experience Measure for Pancreatic Cancer Care (PREPARE) Project: Protocol for a Multi-Method Research Project

Background

Patients with pancreatic cancer do not feel involved in the development of their treatment and care plans. In Belgium, these plans are decided on during multidisciplinary team meetings. However, limited time is spent on the discussion of the preferences of the patient during these meetings. This research project aims to develop a patient-reported experience measure (PREM) for pancreatic cancer and assess if its use can support collaborative treatment decision-making.

Objective

This paper aims to outline the protocol for a multi-method research project to improve person-centered pancreatic cancer care in Belgium. Three subobjectives are pursued: (1) to develop a PREM to assess the experiences of care-related aspects in pancreatic cancer care, (2) to validate the PREM, and (3) to develop and evaluate an educational intervention to support the use of the PREM’s results.

Methods

For the development of the PREM, an exploratory mixed methods study design will be used. The study will start with a survey followed by a telephone interview involving patients with pancreatic cancer and digestive oncology health care professionals. Study two is the testing of the content and construct validity of the PREM. Study three involves the implementation study according to the Medical Research Council framework of a complex intervention introducing the PREM in practice. The effectiveness of the intervention will be investigated using a pragmatic randomized controlled trial study design.

Results

The protocol presents the entire structure of the research project. Ethics approval to conduct the exploratory mixed methods study (objective 1) has been obtained, and recruitment has started since January 2022.

Conclusions

The poor prognosis of patients with pancreatic cancer should not be considered a hurdle to not study this patient population group. Involving patients in the research and decision-making processes early on is key. This project aims to realize a scientifically sound research process providing research outputs that can easily and timely be implemented in the care trajectory of patients with pancreatic cancer. This research project will also lead to recommendations on how to involve patients with pancreatic cancer and how the methodology of this research project can be translated to other patient groups.

International Registered Report Identifier (IRRID)

PRR1-10.2196/29004

The NEVERMIND e-health system in the treatment of depressive symptoms among patients with severe somatic conditions: A multicentre, pragmatic randomised controlled trial

Background

This study assessed the effectiveness of the NEVERMIND e-health system, consisting of a smart shirt and a mobile application with lifestyle behavioural advice, mindfulness-based therapy, and cognitive behavioural therapy, in reducing depressive symptoms among patients diagnosed with severe somatic conditions. Our hypothesis was that the system would significantly decrease the level of depressive symptoms in the intervention group compared to the control group.

Methods

This pragmatic, randomised controlled trial included 425 patients diagnosed with myocardial infarction, breast cancer, prostate cancer, kidney failure, or lower limb amputation. Participants were recruited from hospitals in Turin and Pisa (Italy), and Lisbon (Portugal), and were randomly assigned to either the NEVERMIND intervention or to the control group. Clinical interviews and structured questionnaires were administered at baseline, 12 weeks, and 24 weeks. The primary outcome was depressive symptoms at 12 weeks measured by the Beck Depression Inventory II (BDI-II). Intention-to-treat analyses included 425 participants, while the per-protocol analyses included 333 participants. This trial is registered in the German Clinical Trials Register, DRKS00013391.

Findings

Patients were recruited between Dec 4, 2017, and Dec 31, 2019, with 213 assigned to the intervention and 212 to the control group. The sample had a mean age of 59·41 years (SD=10·70), with 44·24% women. Those who used the NEVERMIND system had statistically significant lower depressive symptoms at the 12-week follow-up (mean difference=-3·03, p<0·001; 95% CI -4·45 to -1·62) compared with controls, with a clinically relevant effect size (Cohen's d=0·39).

Interpretation

The results of this study show that the NEVERMIND system is superior to standard care in reducing and preventing depressive symptoms among patients with the studied somatic conditions.

Funding

The NEVERMIND project received funding from the European Union's Horizon 2020 Research and Innovation Programme under grant agreement No. 689691.

The feasibility of pragmatic influenza vaccine randomized controlled real-world trials in Denmark and England

We estimated the frequency of non-specific influenza-associated clinical endpoints to inform the feasibility of pragmatic randomized controlled trials (RCT) assessing relative vaccine effectiveness (rVE). Hospitalization rates of respiratory, cardiovascular and diabetic events were estimated from Denmark and England's electronic databases and stratified by age, comorbidity and influenza vaccination status. We included a seasonal average of 4.5 million Danish and 7.2 million English individuals, 17 and 32% with comorbidities. Annually, approximately 1% of Danish and 0.5% of English individuals were hospitalized for selected events, ~50% of them respiratory. Hospitalization rates were 40-50-fold and 2-10-fold higher in those >50 years and with comorbidities, respectively. Our findings suggest that a pragmatic RCT using non-specific endpoints is feasible. However, for outcomes with rates <2.5%, it would require randomization of ~100,000 participants to have the power to detect a rVE difference of ~13%. Targeting selected groups (older adults, those with comorbidities) where frequency of events is high would improve trial efficiency.

Comparing two identically protocolized, multicentre, randomized controlled trials on caregiver-mediated exercises poststroke: Any differences across countries?

Background

The evidence for rehabilitation interventions poststroke lack sufficient robustness. However, variation in treatment effects across countries have been given little attention.

Objective

To compare two identically protocolized trials conducted in different western countries in order to identify factors that may have caused variation in secondary trial outcomes.

Methods

Comparative study based on individual patient data (N = 129) from two randomized controlled trials, conducted in hospitals and rehabilitation facilities in the Netherlands (N = 66) and Australia (N = 63). Patients with stroke and their caregivers were randomly allocated to an 8-week caregiver-mediated exercises intervention (N = 63; 31 Australian and 32 Dutch) or to a control group (N = 66; 32 Australian and 34 Dutch). Patient characteristics, compliance, usual care and process measures were compared across countries. We examined if study setting significantly moderated the trial outcomes: Hospital Anxiety and Depression Scale, Fatigue Severity Scale and General Self-Efficacy Scale, measured at 8- and 12 weeks follow-up. In addition, we explored if factors that were significantly different across countries caused variation in these trial outcomes.

Results

Most patients suffered an ischemic stroke, were in the subacute phase and participated with their partner. Dutch patients were younger (P = 0.005) and had a lower functional status (P = 0.001). Australian patients were recruited earlier poststroke (P<0.001), spent less time in exercise therapy (P<0.001) and had a shorter length of stay (P<0.001). The level of contamination was higher (P = 0.040) among Dutch controls. No effect modification was observed and trial outcomes did not change after controlling for cross-country differences.

Conclusions

The present study highlighted important clinical differences across countries whilst using an identical study protocol. The observed differences could result in a different potential for recovery and variation in treatment effects across trials. We argue that we can proceed faster to evaluating interventions within international pragmatic trials.

Use of Real-World Evidence to Drive Drug Development Strategy and Inform Clinical Trial Design

Interest in real-world data (RWD) and real-world evidence (RWE) to expedite and enrich the development of new biopharmaceutical products has proliferated in recent years, spurred by the 21st Century Cures Act in the United States and similar policy efforts in other countries, willingness by regulators to consider RWE in their decisions, demands from third-party payers, and growing concerns about the limitations of traditional clinical trials. Although much of the recent literature on RWE has focused on potential regulatory uses (e.g., product approvals in oncology or rare diseases based on single-arm trials with external control arms), this article reviews how biopharmaceutical companies can leverage RWE to inform internal decisions made throughout the product development process. Specifically, this article will review use of RWD to guide pipeline and portfolio strategy; use of novel sources of RWD to inform product development, use of RWD to inform clinical development, use of advanced analytics to harness "big" RWD, and considerations when using RWD to inform internal decisions. Topics discussed will include the use of molecular, clinicogenomic, medical imaging, radiomic, and patient-derived xenograft data to augment traditional sources of RWE, the use of RWD to inform clinical trial eligibility criteria, enrich trial population based on predicted response, select endpoints, estimate sample size, understand disease progression, and enhance diversity of participants, the growing use of data tokenization and advanced analytical techniques based on artificial intelligence in RWE, as well as the importance of data quality and methodological transparency in RWE.

Leave me out: Patients' characteristics and reasons for opting out of a pragmatic clinical trial involving medication adherence

Opt-out procedures are sometimes used instead of standard consent practices to enable patients to exercise their autonomous preferences regarding research participation while reducing patient and researcher burden. However, little is known about the characteristics of patients who opt-out of research and their reasons for doing so. We gathered such information in a large pragmatic clinical trial (PCT) evaluating the effect of theory informed text messages on medication adherence.Eligible patients, identified through electronic health records, were sent information about the study and provided with an opportunity to opt-out. Those opting out were asked to complete a voluntary survey regarding their reasons for doing so. Demographic data were compared among patients opting-out vs those included in the study using chi-squared tests and a log binomial regression model.Of 9046 patients receiving study packets, 906 (10.0%) patients returned opt-out forms. Of those, 451 (49.8%) returned the opt-out survey. Patients who opted out were more likely to be older, white, and nonHispanic than those who were included in the PCT. Survey respondents expressed high levels of trust in their health care providers, research, and system. Nearly half (46.6%) reported concerns about time as a reason to opt-out.In this PCT, 10% of patients receiving packets opted out, with significant differences in age, race, gender, and ethnicity compared to those included. Future trials should further investigate representativeness and reasons patients choose to opt-out of participating in research.

The GetReal Trial Tool: Design, Assess and Discuss Clinical Drug Trials in Light of RWE Generation

Methodologies incorporating Real World Elements into clinical trial design (also called pragmatic trials) offer an attractive opportunity to assess the effect of a treatment strategy in routine care and as such guide decision making in practice. Uptake of these methods is slow for several reasons, including uncertainty about acceptability of trial results, lack of experience with the methodology and operational challenges. We developed the 'Get Real Trial Tool', an easy-to-use interface, which allows users to assess the impact of design choices on generalisability to routine clinical practice, while taking into account risk of bias, precision, acceptability and operational feasibility. The tool is grounded in the scientific literature on pragmatic trials combined with knowledge of experts from academia, pharmaceutical companies, HTA bodies, patient organisations, and regulators. The aim is to help researchers optimise trial design and facilitate translation of evidence from pragmatic trials to clinical practice. In this paper we describe the development, structure and application of the GetReal Trial Tool.

Improving body image at scale among Brazilian adolescents: study protocol for the co-creation and randomised trial evaluation of a chatbot intervention

BACKGROUND

Body image concerns are prevalent among Brazilian adolescents and can lead to poor psychological and physical health. Yet, there is a scarcity of culturally-appropriate, evidence-based interventions that have been evaluated and made widely available. Chatbot technology (i.e., software that mimics written or spoken human speech) offers an innovative method to increase the scalability of mental health interventions for adolescents. The present protocol outlines the co-creation and evaluation of a body image chatbot for Brazilian adolescents via a partnership between academics, industry organisations and the United Nations Children's Fund (UNICEF).

METHODS

A two-armed fully remote randomised controlled trial will evaluate the chatbot's effectiveness at improving body image and well-being. Adolescent girls and boys (N = 2800) aged 13-18 years recruited online will be randomly allocated (1:1) into either: 1) a body image chatbot or 2) an assessment-only control condition. Adolescents will engage with the chatbot over a 72-hour period on Facebook Messenger. Primary outcomes will assess the immediate and short-term impact of the chatbot on state- and trait-based body image, respectively. Secondary outcomes will include state- and trait-based affect, trait self-efficacy and treatment adherence.

DISCUSSION

This research is the first to develop an evidence-informed body image chatbot for Brazilian adolescents, with the proposed efficacy trial aiming to provide support for accessible, scalable and cost-effective interventions that address disparities in body image prevalence and readily available resources.

TRIAL REGISTRATION NUMBER

NCT04825184 , registered 30th March 2021.

Learning healthcare systems and rapid learning in radiation oncology: Where are we and where are we going?

Learning health systems and rapid-learning are well developed at the conceptual level. The promise of rapidly generating and applying evidence where conventional clinical trials would not usually be practical is attractive in principle. The connectivity of modern digital healthcare information systems and the increasing volumes of data accrued through patients' care pathways offer an ideal platform for the concepts. This is particularly true in radiotherapy where modern treatment planning and image guidance offers a precise digital record of the treatment planned and delivered. The vision is of real-world data, accrued by patients during their routine care, being used to drive programmes of continuous clinical improvement as part of standard practice. This vision, however, is not yet a reality in radiotherapy departments. In this article we review the literature to explore why this is not the case, identify barriers to its implementation, and suggest how wider clinical application might be achieved.

Highly Cited Articles in the Field of Male Infertility and Antioxidants: A Scientometric Analysis

PURPOSE

The objective of this scientometric analysis was to recognize the top 100 cited articles on 'Male infertility and Antioxidants' and analyze its publication characteristics.

MATERIALS AND METHODS

The Scopus database was used to retrieve related articles and the top 100 identified based on citation rate.

RESULTS

The articles were published in 56 journals between 1995 and 2019 with a median (interquartile range) citation score of 17 (5-62). Among the top 100 articles, 69 were clinical studies, which included controlled and blinded (33.33%), prospective (27.54%), randomized-controlled trials (26.09%), uncontrolled (11.59%), and retrospective (1.45%) studies. In addition to conventional semen parameters, advanced sperm function tests such as oxidative stress (51%) and sperm DNA damage (23%) were reported. Pregnancy rate (33%) was found to be the most reported reproductive outcome. Antioxidant therapy was mostly investigated in male cohorts with sperm abnormalities such as asthenozoospermia (28%) and clinical conditions such as idiopathic male infertility (20%), varicocele/varicocelectomy (17%) and general male infertility (16%).

CONCLUSIONS

The most influential publications on antioxidants and male infertility were identified for the first time in the literature. This will serve as a reliable source of information for researchers and clinicians alike.

Pragmatic patient engagement in designing pragmatic oncology clinical trials

Oncology trials are the cornerstone of effective and safe therapeutic discoveries. However, there is increasing demand for pragmatism and patient engagement in the design, implementation and dissemination of oncology trials. Many researchers are uncertain about making trials more practical and even less knowledgeable about how to meaningfully engage patients without compromising scientific rigor to meet regulatory requirements. The present work provides practical guidance for addressing both pragmaticism and meaningful patient engagement. Applying evidence-based approaches like PRECIS-2-tool and the 10-Step Engagement Framework offer practical guidance to make future trials in oncology truly pragmatic and patient-centered. Consequently, such patient-centered trials have improved participation, faster recruitment and greater retention, and uptake of innovative technologies in community-based care.