Communication during the recruitment phase of a multicenter trial: the recruitment hotline

Perspective on optimizing clinical trials in critical care: how to puzzle out recurrent failures

Background

Critical care is a complex field of medicine, especially because of its diversity and unpredictability. Mortality rates of the diseases are usually high and patients are critically ill, admitted in emergency, and often have several overlapping diseases. This makes research in critical care also complex because of patients’ conditions and because of the numerous ethical and regulatory requirements and increasing global competition. Many clinical trials in critical care have thus failed and almost no drug has yet been developed to treat intensive care unit (ICU) patients. Learning from the failures, clinical trials must now be optimized.

Main body

Several aspects can be improved, beginning with the design of studies that should take into account patients’ diversity in the ICU. At the site level, selection should reflect more accurately the potential of recruitment. Management of all players that can be involved in the research at a site level should be a priority. Moreover, training should be offered to all staff members, including the youngest. National and international networks are also part of the future as they create a collective synergy potentially improving the efficacy of sites. Finally, computerization is another area that must be further developed with the appropriate tools.

Conclusion

Clinical research in the ICU is thus a discipline in its own right that still requires tailored approaches. Changes have to be initiated by the investigators themselves as they know all the specificities of the field.

A randomised trial of the effects of an additional communication strategy on recruitment into a large-scale, multi-centre trial

Timely participant recruitment remains a significant challenge for most clinical trials. We evaluated the effects on participant recruitment of communication between the central trial coordinators and the clinical sites in the setting of a large international multi-centre clinical trial. The effects of communication were determined in a single-blind randomised controlled trial involving 167 clinical sites in 19 countries. Clinical sites were randomised to either additional or usual communication strategies - the additional communication group received a communication package based on additional, individually-tailored feedback about recruitment, in addition to the usual correspondence from the central trial coordinators that was provided to the control group. The two study outcomes were the median time to half randomisation target and the median total number of participants randomised per clinical site. Eighty-five clinical centres were randomised to receive additional communication and 82 to receive usual communication. At the conclusion of recruitment, there was no significant difference in the median number of participants randomised per centre between the additional and usual groups (37.5 vs. 37.0, p=0.68). The median time to half randomisation target was lower in the additional communication group compared to the usual group, however this difference did not achieve conventional levels of statistical significance (4.4 months vs. 5.8 months, p=0.08). The findings suggest that the additional communication strategy may be of some incremental benefit in helping sites achieve recruitment targets sooner.

The TEAM methodology for the evaluation of information systems in biomedicine

The TEAM evaluation methodology for information systems in biomedicine (Total Evaluation and Acceptance Methodology) is a unifying methodology for any computer-based information system based on a three dimensional framework; these dimensions being Role, Time and Structure. The theory is derived from how the information system relates to the general system where it should operate, the properties of information flow within a general system and the relation between a system and its models. As a system can in theory be modelled from many perspectives, a perspective to be modelled is built up by formulating criteria relevant to that perspective which can be evaluated by quantitative and qualitative assessment methods. Key characteristics of the methodology include the insistence on a global rather than partial approach to the evaluation of information systems, also the dynamic nature of an information system which is continually in modification as it more successfully deals with the inherent complexity of the environment in which it is operating. The role dimension identifies four main categories, designer, specialist user, end user and stakeholder from which several sub-categories may be identified. The time dimension has four main phases towards relative stability of the information system. The structural dimension distinguishes strategic, tactical or organisational and operational levels that often are confused together with risk of dilution in current approaches. It is believed that this framework and methodology can provide a basis for future standardisation of evaluation methodologies.

Telecommunication technology for the management of large scale clinical trials: the Gissi experience

The Coordinating Centre (CC) of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico (GISSI) used telecommunication technology to develop a computerized network system for the data management of the GISSI studies. Through a personal computer (PC), a communication program, a modem and a telephone line, the investigator in each participating centre can connect with a micro-computer at the CC, to recruit/randomize patients and download reports on the progress of the trial. In the first case, the investigator is required to answer a set of predefined questions, and thereby the system automatically checks eligibility criteria and randomly assigns the patient to a treatment arm. In the second case, once the investigator has made a choice from a list of standard reports and the relative query on CC central database, the generation, the formatting and the transfer of the selected report to the PC are executed automatically on line. The main advantages of this system are a reduction in number of mistakes in data completion and in the human and economic resources required, as well as the real time updating of participating centres. The system was successfully adopted in the GISSI-3 trial (200 Coronary Care Units and 19,394 patients enrolled), in the European arm of the CORE trial and it is currently being used in the GISSI-Prevenzione trial.