The Internet and randomised controlled trials

Report of similar placebo response in one internet versus onsite randomised controlled trials from the literature

Objective

The aim of this study was to compare the magnitude and the predictors of the placebo response in an internet versus onsite randomised controlled trials (RCTs) in people with hand osteoarthritis (HOA).

Method

This study is a post-hoc analysis based on one internet RCT (RADIANT) and previously published onsite RCTs for HOA identified through a rigorous searching and selection strategy. The magnitude of the placebo response in the two different types of RCTs were compared using heterogeneity statistics and forest plots visualisation. Classic placebo predictors as well as a combined model, defined with data from onsite RCTs, were tested to predict the placebo response.

Results

We analysed the dataset from RADIANT and fourteen previously published onsite RCTs. None of the analyses showed a significant difference between the placebo response for the internet versus onsite RCTs. The "classic" placebo predictors combined in a multivariate predictive model correlated significantly with the placebo response measured in RADIANT study.

Conclusion

Despite the absence of face-to-face interactions with the study personnel, there is no evidence that either the magnitude or the predictors of the placebo response of this internet RCT differ from those of onsite RCTs. This analysis is considered as a first step towards evaluating the difference between these designs and strengthens the argument that internet RCTs remain an acceptable alternative way to assess the efficacy of an active treatment in comparison to a placebo.

Design aspects of a distributed clinical trials information system

Backgound Clinical trials informatics has evolved through the development of multiple applications addressing distinct parts of the clinical trials cycle. This setting creates difficulties in the transport and sharing of data among applications that serve a common functionality.

Purpose We present an alternative approach for the design of clinical trials information systems consisting of loosely coupled components standing on a comprehensive model of the global clinical trial process.

Methods We describe how such a structure is able to support the development and implementation of complex knowledge-driven modules, such as automated database query systems, reporting systems and intelligent data-analysis tools, and how currently available internet technologies may be used to support the independent development of applications and collaboration between researchers.

Results These principles were applied to the development of a fully functional system that has been in production for eight years in a diversity of pharmaceutical and academic drug trials. Marked time savings in database set-up and statistical reporting have been documented, as well as good reliability in the selection of appropriate statistical methods to clinical trial data analysis.

Conclusions In order to meet the expected functionality and to avoid the proliferation of databases and software applications, clinical trials information systems need to be based on a generic model of clinical trials and on a distributed architecture.

Creating a database of internet-based clinical trials to support a public-led research programme: A descriptive analysis

Background

Online trials are rapidly growing in number, offering potential benefits but also methodological, ethical and social challenges. The International Network for Knowledge on Well-being (ThinkWell™) aims to increase public and patient participation in the prioritisation, design and conduct of research through the use of technologies.

Objective

We aim to provide a baseline understanding of the online trial environment, determining how many trials have used internet-based technologies; how they have been used; and how use has developed over time.

Methods

We searched a range of bibliographic databases to March 2015, with no date limits, supplemented by citation searching and references provided by experts in the field. Results were screened against inclusion and exclusion criteria, and included studies mapped against a number of key dimensions, with key themes developed iteratively throughout the process.

Results

We identified 1992 internet-based trials to March 2015. The number of reported studies increased substantially over the study timeframe. The largest number of trials were conducted in the USA (49.7%), followed by The Netherlands (10.2%); Australia (8.5%); the United Kingdom (5.8%); Sweden (4.6%); Canada (4%); and Germany (2.6%). South Korea (1.5%) has the highest number of reported trials for other continents. There is a predominance of interventions addressing core public health challenges including obesity (8.6%), smoking cessation (5.9%), alcohol abuse (7.7%) and physical activity (10.2%); in mental health issues such as depression (10.9%) and anxiety (5.6%); and conditions where self-management (16.6%) or monitoring (8.1%) is a major feature of care.

Conclusions

The results confirm an increase in the use of the internet in trials. Key themes have emerged from the analysis and further research will be undertaken in order to investigate how the data can be used to improve trial design and recruitment, and to build an open access resource to support the public-led research agenda.

Turning Access into a web-enabled secure information system for clinical trials

BACKGROUND

Organizations that have limited resources need to conduct clinical studies in a cost-effective, but secure way. Clinical data residing in various individual databases need to be easily accessed and secured. Although widely available, digital certification, encryption, and secure web server, have not been implemented as widely, partly due to a lack of understanding of needs and concerns over issues such as cost and difficulty in implementation.

PURPOSE

The objective of this study was to test the possibility of centralizing various databases and to demonstrate ways of offering an alternative to a large-scale comprehensive and costly commercial product, especially for simple phase I and II trials, with reasonable convenience and security.

METHODS

We report a working procedure to transform and develop a standalone Access database into a secure Web-based secure information system.

RESULTS

For data collection and reporting purposes, we centralized several individual databases; developed, and tested a web-based secure server using self-issued digital certificates.

LIMITATIONS

The system lacks audit trails. The cost of development and maintenance may hinder its wide application.

CONCLUSIONS

The clinical trial databases scattered in various departments of an institution could be centralized into a web-enabled secure information system. The limitations such as the lack of a calendar and audit trail can be partially addressed with additional programming. The centralized Web system may provide an alternative to a comprehensive clinical trial management system.

Web-based randomised controlled trials in orthodontics

Randomised controlled trials (RCT) are considered the best source of scientific evidence--the gold standard--when evaluating the efficacy of orthodontic treatments. Frequently, RCT are planned as multicentre trials, with the intention of increasing statistical power and raising the precision of outcome estimates. The management of large-scale RCT, however, requires even more thorough organisation than conventional RCT. Indeed, the need for high accuracy and standardisation in data collection, research aids, secretarial skills, staff and patient training, and organisational meetings, make these studies time-consuming, expensive and, in general, relatively complex to carry out well. A website was developed to support a large scale-orthodontic RCT which aimed to evaluate the efficacy of a functional appliance(www.ortodonzia.unina.it). Websites such as this can increase the quality of data collection, simplify the randomisation process, speed up data collection, and improve trial monitoring. Web-based RCT have the potential to help globalise orthodontic research and also increase our rate of acquisition of evidence in orthodontics.

Perceived norms and mental health help seeking among African American college students

In general, African Americans do not seek mental health treatment from formal sources at the same rates as Caucasians. The present study examined whether culturally relevant factors (i.e., perceived negative peer and family norms about help seeking) influence help-seeking intentions in a late adolescent African-American sample (n = 219) and whether there is a gender difference in the predictive strength between peer and family norms. Participants were primarily female (n = 144). Multiple regressions were implemented to explore the relationship between perceived norms and help-seeking intentions. Analyses revealed that males had higher perceived peer norms, and family norms were a stronger predictor of intentions than peer norms for females. Individually, peer norms and family norms were related to help-seeking intentions. When perceived norms were analyzed together, only negative family norms were related to intentions. Findings suggest that incorporating family norms is critical when developing interventions to increase formal service utilization among African Americans.

LISA: a web-based decision-support system for trial management of childhood acute lymphoblastic leukaemia

Continuation chemotherapy is a key component of the treatment of childhood acute lymphoblastic leukaemia. During this treatment phase, weekly dose adjustments are carried out based on current and historical full blood counts (FBCs). The dose decision pathway is complex and suboptimal therapy may result if information on FBC results is not readily available and/or the prescriber is inexperienced. A web-based decision-support system (Leukaemia Intervention Scheduling and Advice, 'LISA') was designed to facilitate access to FBC information across geographical locations and to assist with dosage adjustments. A balanced-block crossover analysis was performed to evaluate the system. Thirty-six clinicians with varying degrees of experience were each asked to decide on appropriate oral chemotherapy dosages for eight simulated cases: four using LISA and four without. LISA significantly reduced the number of erroneous prescriptions (zero of 144 with LISA vs. 54 of 144 without; P < 0.0001) without affecting the number of times subjects deliberately overrode the protocol (seven of 144 times using LISA and six of 144 without). Using LISA reduced the time taken by novices to reach a decision for each case but increased the time taken by experts. Thirty-five of 36 subjects said they would be likely to use the system if it were available. A system like LISA is likely to be acceptable to clinicians, and has the potential to increase protocol compliance and decrease prescribing errors while allowing clinicians to override the protocol in specific cases where sound reasons exist for doing so.

The Internet and clinical trials: background, online resources, examples and issues

Both the Internet and clinical trials were significant developments in the latter half of the twentieth century: the Internet revolutionized global communications and the randomized controlled trial provided a means to conduct an unbiased comparison of two or more treatments. Large multicenter trials are often burdened with an extensive development time and considerable expense, as well as significant challenges in obtaining, backing up and analyzing large amounts of data. Alongside the increasing complexities of the modern clinical trial has grown the power of the Internet to improve communications, centralize and secure data as well as to distribute information. As more and more clinical trials are required to coordinate multiple trial processes in real time, centers are turning to the Internet for the tools to manage the components of a clinical trial, either in whole or in part, to produce lower costs and faster results. This paper reviews the historical development of the Internet and the randomized controlled trial, describes the Internet resources available that can be used in a clinical trial, reviews some examples of online trials and describes the advantages and disadvantages of using the Internet to conduct a clinical trial. We also extract the characteristics of the 5 largest clinical trials conducted using the Internet to date, which together enrolled over 26000 patients.

Internet based multi-institutional clinical research: a convenient and secure option

PURPOSE

As randomized, prospective trials have become an integral part of clinical research, multi-institutional, collaborative research has become a necessity. However, it may be cumbersome for participants at remote facilities to participate because the submission and compilation of data and results are at times lengthy processes. Internet based clinical studies have been found to be a rapid, easily accessible, safe and secure method of performing multi-institutional trials.

MATERIALS AND METHODS

The Internet was used at geographically distant medical centers to enroll patients into a multi-institutional, prospective, randomized trial for the management of lower pole renal calculi. The Clinical Research Web-based Information Center secure computer web based program (Simplified Clinical Data Systems, Amherst, New Hampshire) was established to input preliminary demographic and clinical data, randomize patients, and collect treatment and followup information without paper chart documentation. The primary investigators in the study were sent a questionnaire to determine the ease of use of this Internet based program. The results were tabulated.

RESULTS

A total of 112 patients from 21 participating institutions were randomized into the secure web site for inclusion into a lower pole renal stone clinical trial. Of the investigators 64% responded to the questionnaire. The majority of those having enrolled patients into the study reported no difficulties or only minimal difficulties in navigating the web site. Moreover, investigators from remote locations throughout North America described the improved convenience, rapid transmission of information, and ability to review and update patient data as benefits of enrolling patients using the Internet. The Internet based system also permits the prompt compilation of data at the host research site for performing interim data assessments and eventually the final analysis.

CONCLUSIONS

A web based data collection center allows for large, multi-institutional trials to be done with unprecedented accuracy and efficiency. Through centralization of data capture, and real-time study monitoring and data analysis the system removes these responsibilities from those at individual test sites, permitting investigators to concentrate instead on other aspects of the study and its progress. State-of-the-art security protects all information to ensure confidentiality. The Internet may prove to be an invaluable tool in the future of clinical research.

Can clinical trials requiring frequent participant contact be conducted over the Internet? Results from an online randomized controlled trial evaluating a topical ointment for herpes labialis

Background

The Internet has tremendous appeal for conducting randomized clinical trials and may be especially applicable to trials requiring frequent participant contact. Trials of cold sore remedies, for example, often require daily clinic visits during outbreaks, imposing substantial burden on participants. An Internet-based randomized clinical trial design may reduce this burden, permitting frequent symptom reports with considerably less effort.

Objective

To evaluate the feasibility of a Web-based randomized clinical trial requiring frequent participant interaction, using a 6-month, double-blind, randomized, placebo-controlled pilot trial of a topical ointment containing dioctyl sodium sulfosuccinate (DSS) (Zilex; Meditech Pharmaceuticals, Inc, Scottsdale, Arizona, USA) intended for treatment of recurrent herpes labialis. A secondary objective was to obtain preliminary data on effectiveness outcomes, to assist in planning a fully-powered trial of DSS.

Methods

Adults with physician-confirmed herpes labialis were recruited to apply to the trial. Eligible applicants were randomized to DSS or placebo, mailed to them upon enrolment with instructions to apply topically every 2 hours for the duration of every cold sore outbreak. Participants were instructed to complete online questionnaires at 2-week intervals and, at the initiation of a cold sore, daily "outbreak questionnaires" until outbreak termination. Feasibility outcome measures included trial participant characteristics, frequency of cold sores, participant retention and adherence (to study medication), and data completeness. Treatment effectiveness outcome measures included outbreak duration, days to crust formation, and pain.

Results

Of the 292 individuals applying, 182 screened eligible; 32 participants with confirmed herpes labialis enrolled in the trial. 16 were randomized into the verum group and 16 into the placebo group. 29 (91%) participants completed the trial. During the trial, 34 outbreaks were reported among 23 (72%) participants, resulting in a cold sore incidence rate of 19.8 per 100 person-months of observation. Online data were available for 32 outbreaks; the absence of a resolution date made it impossible to accurately calculate the duration of 12 (38%) outbreaks. Although the DSS treatment group had a shorter mean outbreak duration (6.6 vs 7.7 days, P= .2) and fewer mean days to crust formation (3.5 vs 4.9, P= .1), these differences did not reach statistical significance. The DSS group has statistically significant lower mean pain scores (3.1 vs 7.6, P= .04), but participants in this group also consumed more acetaminophen tablets than the placebo group (1.1 versus 0.5, P=.55). Adherence to medication was similar in both groups: 7 (50%) of the verum group reported using the cream as directed compared to 6 (46.2%) in the placebo group; ( P= .8).

Conclusions

We efficiently recruited participants and achieved high overall retention rates. However, participant adherence to the daily outbreak visit schedules was low and only 7 (50%) participants used the cream as directed. These limitations could be addressed in future Internet-based studies by using Personal Digital Assistants (PDAs), using reminder devices, and providing incentives. By enhancing participant adherence, clinical trials requiring frequent participant contact may be feasible over the Internet.

Measurement issues related to data collection on the World Wide Web

As the World Wide Web has become more prominent as a mode of communication, it has opened up new possibilities for research data collection. This article identifies measurement issues that occur with Internet data collection that are relevant to qualitative and quantitative research approaches as they occurred in a triangulated Internet study of perimenopausal women with migraine headaches. Issues associated with quantitative data collection over the Internet include (a) selecting and designing Internet data collection protocols that adequately address study aims while also taking advantage of the Internet, (b) ensuring the reliability and validity of Internet data collected, (c) adapting quantitative paper-and-pencil data collection protocols for the Internet, (d) making Internet data collection practical for respondents and researchers, and (e) ensuring the quality of quantitative data collected. Qualitative data collection over the Internet needs to remain true to the philosophical stance of the qualitative approach selected. Researcher expertise in qualitative data collection must be combined with expertise in computer technology and information services if data are to be of ultimate quality The advantages and limitations of collecting qualitative data in real time or at a later time are explored, as well as approaches to enhance qualitative data collection over the Internet. It was concluded that like any research approach or method, Internet data collection requires considerable creativity, expertise, and planning to take advantage of the technology for the collection of reliable and valid research data.

Conducting clinical trials over the internet: feasibility study

Can randomised controlled trials be successfully conducted over the internet? The authors report a feasibility study of such a trial in patients with osteoarthritis of the knee

Using the Internet for surveys and health research

This paper concerns the use of the Internet in the research process, from identifying research issues through qualitative research, through using the Web for surveys and clinical trials, to pre-publishing and publishing research results. Material published on the Internet may be a valuable resource for researchers desiring to understand people and the social and cultural contexts within which they live outside of experimental settings, with due emphasis on the interpretations, experiences, and views of 'real world' people. Reviews of information posted by consumers on the Internet may help to identify health beliefs, common topics, motives, information, and emotional needs of patients, and point to areas where research is needed. The Internet can further be used for survey research. Internet-based surveys may be conducted by means of interactive interviews or by questionnaires designed for self-completion. Electronic one-to-one interviews can be conducted via e-mail or using chat rooms. Questionnaires can be administered by e-mail (e.g. using mailing lists), by posting to newsgroups, and on the Web using fill-in forms. In "open" web-based surveys, selection bias occurs due to the non-representative nature of the Internet population, and (more importantly) through self-selection of participants, i.e. the non-representative nature of respondents, also called the 'volunteer effect'. A synopsis of important techniques and tips for implementing Web-based surveys is given. Ethical issues involved in any type of online research are discussed. Internet addresses for finding methods and protocols are provided. The Web is also being used to assist in the identification and conduction of clinical trials. For example, the web can be used by researchers doing a systematic review who are looking for unpublished trials. Finally, the web is used for two distinct types of electronic publication. Type 1 publication is unrefereed publication of protocols or work in progress (a 'post-publication' peer review process may take place), whereas Type 2 publication is peer-reviewed and will ordinarily take place in online journals.

The use of handheld computers in clinical trials

A recently completed, randomized, double-blind placebo-controlled clinical trial is presented in which Palm handheld computers were used as a substitute for normal paper-based patient diaries. In this nasal provocation study, a common antihistamine approved for the treatment of seasonal allergic rhinitis was tested against placebo for evidence of additional properties. In addition to their medical examinations, the 12 study volunteers rated subjective complaints in a diary program on 4 examination days, for a duration of 4.5 hours every 15 minutes at each visit. This resulted in 903 data sets consisting of five questions each, or 4515 data points total. In this study the use of handheld computers resulted in an increase in data quality and shortened the time needed to close the database. Moreover, the benefit of electronic reminders for protocol compliance is clearly demonstrated. Our findings support the results found in the literature we reviewed. For more than 16 years, mobile computers have been supporting the implementation of clinical trials. Our review of 27 articles out of more than 100 clinical trials in which mobile computers have been used elaborates on the advantages and problems of this technology. We give a comprehensive overview of the various technologies as used in different settings, and then discuss the methodology of using mobile devices in comparison to traditional methods, the considerations that need to be made and things to be avoided in order to conduct a successful clinical trial with mobile tools. We conclude that mobile devices are very useful in most cases, especially when design and software validation aspects have been taken into account.

The Internet in oncology nursing

OBJECTIVES

To explore the implications of the internet for oncology nursing practice, education, and research.

DATA SOURCES

Published articles, texts, research studies, review articles, and online documents pertaining to the internet.

CONCLUSIONS

The internet has influenced nearly every aspect of society. As the worldwide communications infrastructure strengthens, access devices become affordable, and more countries contribute content in their native language, this technology becomes a truly global phenomenon. This affords oncology nursing a voice that extends beyond the community support group to millions of internet users.

IMPLICATIONS FOR NURSING PRACTICE

Internet access, quality of information, and privacy of data transmitted are among the greatest challenges that face oncology nurses who integrate this technology into practice.

Multimedia computer database for neurosurgery

OBJECTIVE

There is a need for an efficient mechanism of storing and analyzing neurosurgical clinical, imaging, and operative data to facilitate clinical audit, research, education, and preparation of scientific presentations.

METHODS

A computer database was developed to meet this need. The recorded data include diagnoses, digitized neuroimaging studies, operative details (with intraoperative video clips), transcranial Doppler studies, outcomes, complications, admissions, and clinic visits. The anatomy, pathology, and clinical presentation are recorded for each diagnosis.

RESULTS

The database provides an audit of neurosurgery cases, which includes admission Glasgow Coma Scale score, length of intensive care and hospital stays, Glasgow Outcome Scale score, and complications. Clinical research is facilitated by flexible search strategies based on the anatomy, pathology, or clinical presentation of diseases, or any of the recorded intraoperative or outcome factors. The system can be used to assess the influence on outcome of factors, such as transcranial Doppler velocity, intraoperative blood pressure, and the use of ventricular drainage, intraoperative angiography, or temporary clipping. The database can be used to track patients with untreated or partially treated conditions, such as incidental or incompletely coiled aneurysms. The recorded images and video clips are used for teaching and producing multimedia presentations and reports. The database is designed to enable secure Internet connections among institutions so that outcomes and complications can be compared among surgeons and institutions.

CONCLUSION

This multimedia computer database facilitates clinical audit, research, teaching, and presentation activities.