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Eisenstein EL, Hill KD, Wood N, Kirchner JL, Anstrom KJ, Granger CB, Rao SV, Baldwin HS, Jacobs JP, Jacobs ML, Kannankeril PJ, Graham EM, O'Brien SM, Li JS. Evaluating registry-based trial economics: Results from the STRESS clinical trial. Contemp Clin Trials Commun 2024; 38:101257. [PMID: 38298917 PMCID: PMC10826145 DOI: 10.1016/j.conctc.2024.101257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/18/2023] [Accepted: 01/08/2024] [Indexed: 02/02/2024] Open
Abstract
Background Registry-based trials have the potential to reduce randomized clinical trial (RCT) costs. However, observed cost differences also may be achieved through pragmatic trial designs. A systematic comparison of trial costs across different designs has not been previously performed. Methods We conducted a study to compare the current Steroids to Reduce Systemic inflammation after infant heart surgery (STRESS) registry-based RCT vs. two established designs: pragmatic RCT and explanatory RCT. The primary outcome was total RCT design costs. Secondary outcomes included: RCT duration and personnel hours. Costs were estimated using the Duke Clinical Research Institute's pricing model. Results The Registry-Based RCT estimated duration was 31.9 weeks greater than the other designs (259.5 vs. 227.6 weeks). This delay was caused by the Registry-Based design's periodic data harvesting that delayed site closing and statistical reporting. Total personnel hours were greatest for the Explanatory design followed by the Pragmatic design and the Registry-Based design (52,488 vs 29,763 vs. 24,480 h, respectively). Total costs were greatest for the Explanatory design followed by the Pragmatic design and the Registry-Based design ($10,140,263 vs. $4,164,863 vs. $3,268,504, respectively). Thus, Registry-Based total costs were 32 % of the Explanatory and 78 % of the Pragmatic design. Conclusion Total costs for the STRESS RCT with a registry-based design were less than those for a pragmatic design and much less than an explanatory design. Cost savings reflect design elements and leveraging of registry resources to improve cost efficiency, but delays to trial completion should be considered.
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Affiliation(s)
| | - Kevin D. Hill
- Duke Clinical Research Institute, Durham, NC, USA
- Duke Pediatric and Congenital Heart Center, Durham, NC, USA
| | - Nancy Wood
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Kevin J. Anstrom
- Collaborative Studies Coordinating Center, Chapel Hill, NC, USA
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | | | | | - H. Scott Baldwin
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | | | - Eric M. Graham
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Jennifer S. Li
- Duke Clinical Research Institute, Durham, NC, USA
- Duke Pediatric and Congenital Heart Center, Durham, NC, USA
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Kir F, Al-Sulaiti FK, Sahin S. Evaluation of in vitro dissolution profiles of modified-release metoprolol succinate tablets crushed using mortar and pestle technique. Eur J Pharm Sci 2024; 194:106694. [PMID: 38191064 DOI: 10.1016/j.ejps.2024.106694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 12/24/2023] [Accepted: 01/04/2024] [Indexed: 01/10/2024]
Abstract
PURPOSE Clinical practice guidelines advise against crushing modified-release dosage forms. Metoprolol succinate modified-release (MS-MR) tablets are commonly crushed in clinical practice to facilitate administration to patients with swallowing difficulties or using feeding tubes. To date, the effect of this practice remains unexplored. The in vitro effects of crushing commercially available MS-MR tablets were explored using a holistic approach. METHODS Dissolution profiles of crushed versus whole MS-MR tablets were compared. Tablets were crushed to powder state using pragmatic method mimicking hospital practices. For standardization purposes, the same operator, duration (60 seconds), hand, and mortar-pestle apparatus were used. Dissolution studies were conducted per U.S. Pharmacopeia at pH 1.2, pH 4.5, and pH 6.8 with USP apparatus 2 (paddle) at rotation speed of 50 rpm at 37±0.5 °C in 500 mL dissolution media. Samples were withdrawn at predetermined time points. Percent drug dissolved was measured by validated UV-vis Spectrophotometry. Comprehensive analysis of the dissolution data was conducted using model-independent, model-dependent, and ANOVA-based approaches (SPSS v.23 at α=0.05). Similarity (f2) and difference (f1) factors were calculated to compare the dissolution profiles between crushed (CT) and whole tablets (WT). Goodness of fit (GOF) analysis examined the compliance between in vitro dissolution behaviors and several drug release models. Model selection was based on GOF plots, Akaike criteria and adjusted coefficient of determination (R2adj). Imaging and particle size distribution analysis were conducted to examine associated surface and morphologic changes. RESULTS The dissolution profiles were not similar at pH 4.5 (f2=45.43, f1=18.97) and pH 6.8 (f2=31.47, f1=32.94). CT best fitted with Higuchi (pH 1.2: R2adj=0.9990), Weibull (pH 4.5: R2adj=0.9884), and Korsmeyer-Peppas (pH 6.8: R2adj=0.9719). Contrastingly, WT best fitted with Hopfenberg (pH 1.2: R2adj=0.9986), logistic (pH 4.5: R2adj=0.9839) and first-order (pH 6.8: R2adj=0.9979) models. A significant difference in the dissolution profiles was found between CT and WT using multivariate analysis of variance per time points and between the tablet forms (p=0.004). This was confirmed by unparalleled dissolution profiles. Crushing resulted in variations in particle size and surface morphological changes to the micropellets. CONCLUSION Crushing practices change the dissolution profile of MS-MR tablets by deforming the surface morphology of embedded micropellets. Amounts of drug dissolved between CT and WT were not the same at the compared time points across gastrointestinal pH ranges. This suggests potential clinical impact on plasma-concentration profiles of critically ill patients using feeding tube.
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Affiliation(s)
- Fatma Kir
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
| | - Fatima K Al-Sulaiti
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
| | - Selma Sahin
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey.
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Chen Y, Shah A, Jani Y, Higgins D, Saleem N, Chafer K, Sydes MR, Asselbergs FW, Lumbers RT. Rationale and design of the THIRST Alert feasibility study: a pragmatic, single-centre, parallel-group randomised controlled trial of an interruptive alert for oral fluid restriction in patients treated with intravenous furosemide. BMJ Open 2024; 14:e080410. [PMID: 38216198 PMCID: PMC10806795 DOI: 10.1136/bmjopen-2023-080410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/11/2023] [Indexed: 01/14/2024] Open
Abstract
INTRODUCTION Acute heart failure (HF) is a major cause of unplanned hospitalisation characterised by excess body water. A restriction in oral fluid intake is commonly imposed on patients as an adjunct to pharmacological therapy with loop diuretics, but there is a lack of evidence from traditional randomised controlled trials (RCTs) to support the safety and effectiveness of this intervention in the acute setting.This study aims to explore the feasibility of using computer alerts within the electronic health record (EHR) system to invite clinical care teams to enrol patients into a pragmatic RCT at the time of clinical decision-making. It will additionally assess the effectiveness of using an alert to help address the clinical research question of whether oral fluid restriction is a safe and effective adjunct to pharmacological therapy for patients admitted with fluid overload. METHODS AND ANALYSIS THIRST (Randomised Controlled Trial within the electronic Health record of an Interruptive alert displaying a fluid Restriction Suggestion in patients with the treatable Trait of congestion) Alert is a single-centre, parallel-group, open-label pragmatic RCT embedded in the EHR system that will be conducted as a feasibility study at an National Health Service (NHS) hospital in London. The clinical care team will be invited to enrol suitable patients in the study using a point-of-care alert with a target sample size of 50 patients. Enrolled patients will then be randomised to either restricted or unrestricted oral fluid intake. Two primary outcomes will be explored (1) the proportion of eligible patients enrolled in the study and (2) the mean difference in oral fluid intake between randomised groups. A series of secondary outcomes are specified to evaluate the effectiveness of the alert, adherence to the randomised treatment allocation and the quality of data generated from routine care, relevant to the outcomes of interest. ETHICS AND DISSEMINATION This study was approved by Riverside Research Ethics Committee (Ref: 22/LO/0889) and will be published on completion. TRIAL REGISTRATION NUMBER NCT05869656.
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Affiliation(s)
- Yang Chen
- Institute of Health Informatics, University College London, London, UK
- Clinical and Research Informatics Unit, NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Anoop Shah
- Institute of Health Informatics, University College London, London, UK
- Clinical and Research Informatics Unit, NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Yogini Jani
- Centre for Medicines Optimisation Research & Education - CMORE, University College London Hospitals NHS Foundation Trust, London, UK
| | - Daniel Higgins
- Clinical and Research Informatics Unit, NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Nausheen Saleem
- Clinical and Research Informatics Unit, NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Kris Chafer
- Clinical and Research Informatics Unit, NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Matthew Robert Sydes
- Institute of Clinical Trials and Methodology, Medical Research Council Clinical Trials Unit at University College London, London, UK
- Health Data Research UK, London, UK
| | - Folkert W Asselbergs
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - R Thomas Lumbers
- Institute of Health Informatics, University College London, London, UK
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Khan MS, Usman MS, Van Spall HGC, Greene SJ, Baqal O, Felker GM, Bhatt DL, Januzzi JL, Butler J. Endpoint adjudication in cardiovascular clinical trials. Eur Heart J 2023; 44:4835-4846. [PMID: 37935635 DOI: 10.1093/eurheartj/ehad718] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023] Open
Abstract
Endpoint adjudication (EA) is a common feature of contemporary randomized controlled trials (RCTs) in cardiovascular medicine. Endpoint adjudication refers to a process wherein a group of expert reviewers, known as the clinical endpoint committee (CEC), verify potential endpoints identified by site investigators. Events that are determined by the CEC to meet pre-specified trial definitions are then utilized for analysis. The rationale behind the use of EA is that it may lessen the potential misclassification of clinical events, thereby reducing statistical noise and bias. However, it has been questioned whether this is universally true, especially given that EA significantly increases the time, effort, and resources required to conduct a trial. Herein, we compare the summary estimates obtained using adjudicated vs. non-adjudicated site designated endpoints in major cardiovascular RCTs in which both were reported. Based on these data, we lay out a framework to determine which trials may warrant EA and where it may be redundant. The value of EA is likely greater when cardiovascular trials have nuanced primary endpoints, endpoint definitions that align poorly with practice, sub-optimal data completeness, greater operator variability, and lack of blinding. EA may not be needed if the primary endpoint is all-cause death or all-cause hospitalization. In contrast, EA is likely merited for more nuanced endpoints such as myocardial infarction, bleeding, worsening heart failure as an outpatient, unstable angina, or transient ischaemic attack. A risk-based approach to adjudication can potentially allow compromise between costs and accuracy. This would involve adjudication of a small proportion of events, with further adjudication done if inconsistencies are detected.
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Affiliation(s)
- Muhammad Shahzeb Khan
- Division ofCardiology, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27705, USA
| | - Muhammad Shariq Usman
- Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Department of Medicine, Parkland Health and Hospital System, Dallas, TX, USA
| | - Harriette G C Van Spall
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Research Institute of St Joe's, Hamilton, Ontario, Canada
| | - Stephen J Greene
- Division ofCardiology, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27705, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Omar Baqal
- Department of Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Gary Michael Felker
- Division ofCardiology, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27705, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, NewYork, NY, USA
| | - James L Januzzi
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Baim Institute for Clinical Research, Boston, MA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, 3434 Oak Street Ste 501, Dallas, TX 75204, USA
- Department of Medicine, University of Mississippi School of Medicine, 2500 N State St, Jackson, MS, USA
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Leviton A, Loddenkemper T. Design, implementation, and inferential issues associated with clinical trials that rely on data in electronic medical records: a narrative review. BMC Med Res Methodol 2023; 23:271. [PMID: 37974111 PMCID: PMC10652539 DOI: 10.1186/s12874-023-02102-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
Real world evidence is now accepted by authorities charged with assessing the benefits and harms of new therapies. Clinical trials based on real world evidence are much less expensive than randomized clinical trials that do not rely on "real world evidence" such as contained in electronic health records (EHR). Consequently, we can expect an increase in the number of reports of these types of trials, which we identify here as 'EHR-sourced trials.' 'In this selected literature review, we discuss the various designs and the ethical issues they raise. EHR-sourced trials have the potential to improve/increase common data elements and other aspects of the EHR and related systems. Caution is advised, however, in drawing causal inferences about the relationships among EHR variables. Nevertheless, we anticipate that EHR-CTs will play a central role in answering research and regulatory questions.
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Affiliation(s)
- Alan Leviton
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Tobias Loddenkemper
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Avram R, Byrne J, So D, Iturriaga E, Lennon R, Murthy V, Geller N, Goodman S, Rihal C, Rosenberg Y, Bailey K, Farkouh M, Bell M, Cagin C, Chavez I, El-Hajjar M, Ginete W, Lerman A, Levisay J, Marzo K, Nazif T, Tanguay JF, Pletcher M, Marcus GM, Pereira NL, Olgin J. Digital Tool-Assisted Hospitalization Detection in the Tailored Antiplatelet Initiation to Lessen Outcomes due to Decreased Clopidogrel Response After Percutaneous Coronary Intervention Study Compared to Traditional Site-Coordinator Ascertainment: Intervention Study. J Med Internet Res 2023; 25:e47475. [PMID: 37948098 PMCID: PMC10674150 DOI: 10.2196/47475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/12/2023] [Accepted: 09/11/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Accurate, timely ascertainment of clinical end points, particularly hospitalizations, is crucial for clinical trials. The Tailored Antiplatelet Initiation to Lessen Outcomes Due to Decreased Clopidogrel Response after Percutaneous Coronary Intervention (TAILOR-PCI) Digital Study extended the main TAILOR-PCI trial's follow-up to 2 years, using a smartphone-based research app featuring geofencing-triggered surveys and routine monthly mobile phone surveys to detect cardiovascular (CV) hospitalizations. This pilot study compared these digital tools to conventional site-coordinator ascertainment of CV hospitalizations. OBJECTIVE The objectives were to evaluate geofencing-triggered notifications and routine monthly mobile phone surveys' performance in detecting CV hospitalizations compared to telephone visits and health record reviews by study coordinators at each site. METHODS US and Canadian participants from the TAILOR-PCI Digital Follow-Up Study were invited to download the Eureka Research Platform mobile app, opting in for location tracking using geofencing, triggering a smartphone-based survey if near a hospital for ≥4 hours. Participants were sent monthly notifications for CV hospitalization surveys. RESULTS From 85 participants who consented to the Digital Study, downloaded the mobile app, and had not previously completed their final follow-up visit, 73 (85.8%) initially opted in and consented to geofencing. There were 9 CV hospitalizations ascertained by study coordinators among 5 patients, whereas 8 out of 9 (88.9%) were detected by routine monthly hospitalization surveys. One CV hospitalization went undetected by the survey as it occurred within two weeks of the previous event, and the survey only allowed reporting of a single hospitalization. Among these, 3 were also detected by the geofencing algorithm, but 6 out of 9 (66.7%) were missed by geofencing: 1 occurred in a participant who never consented to geofencing, while 5 hospitalizations occurred among participants who had subsequently turned off geofencing prior to their hospitalization. Geofencing-detected hospitalizations were ascertained within a median of 2 (IQR 1-3) days, monthly surveys within 11 (IQR 6.5-25) days, and site coordinator methods within 38 (IQR 9-105) days. The geofencing algorithm triggered 245 notifications among 39 participants, with 128 (52.2%) from true hospital presence and 117 (47.8%) from nonhospital health care facility visits. Additional geofencing iterative improvements to reduce hospital misidentification were made to the algorithm at months 7 and 12, elevating the rate of true alerts from 35.4% (55 true alerts/155 total alerts before month 7) to 78.7% (59 true alerts/75 total alerts in months 7-12) and ultimately to 93.3% (14 true alerts/5 total alerts in months 13-21), respectively. CONCLUSIONS The monthly digital survey detected most CV hospitalizations, while the geofencing survey enabled earlier detection but did not offer incremental value beyond traditional tools. Digital tools could potentially reduce the burden on study coordinators in ascertaining CV hospitalizations. The advantages of timely reporting via geofencing should be weighed against the issue of false notifications, which can be mitigated through algorithmic refinements.
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Affiliation(s)
- Robert Avram
- University of California San Francisco, San Francisco, CA, United States
- Department of Medicine, Montréal Heart Institute, Université de Montreal, Montréal, QC, Canada
| | - Julia Byrne
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Derek So
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Erin Iturriaga
- University of Ottawa Heart Institute, Ottawa, MD, United States
| | - Ryan Lennon
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Vishakantha Murthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Nancy Geller
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Shaun Goodman
- St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Charanjit Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Yves Rosenberg
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Kent Bailey
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | | | - Malcolm Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Charles Cagin
- Mayo Clinic Health Systems, La Crosse, WI, United States
| | - Ivan Chavez
- Minneapolis Heart Institute, Minneapolis, MN, United States
| | | | - Wilson Ginete
- Essentia Institute of Rural Health, Duluth, MN, United States
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Justin Levisay
- NorthShore University Health System, Evanston, IL, United States
| | - Kevin Marzo
- Winthrop University Hospital, Mineola, NY, United States
| | - Tamim Nazif
- Columbia University Medical Center, New York, NY, United States
| | | | - Mark Pletcher
- University of California San Francisco, San Francisco, CA, United States
| | - Gregory M Marcus
- University of California San Francisco, San Francisco, CA, United States
| | - Naveen L Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jeffrey Olgin
- University of California San Francisco, San Francisco, CA, United States
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Scheen AJ. Pragmatic trials, a step forward to assess cardiovascular efficacy of new glucose-lowering agents. Lancet Diabetes Endocrinol 2023; 11:626-627. [PMID: 37499674 DOI: 10.1016/s2213-8587(23)00161-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 05/30/2023] [Indexed: 07/29/2023]
Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, B-4000 Liège, Belgium; Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium.
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Jalloh MB, Averbuch T, Kulkarni P, Granger CB, Januzzi JL, Zannad F, Yeh RW, Yancy CW, Fonarow GC, Breathett K, Gibson CM, Van Spall HGC. Bridging Treatment Implementation Gaps in Patients With Heart Failure: JACC Focus Seminar 2/3. J Am Coll Cardiol 2023; 82:544-558. [PMID: 37532425 PMCID: PMC10614026 DOI: 10.1016/j.jacc.2023.05.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/19/2023] [Accepted: 05/25/2023] [Indexed: 08/04/2023]
Abstract
Heart failure (HF) is a leading cause of death and disability in older adults. Despite decades of high-quality evidence to support their use, guideline-directed medical therapies (GDMTs) that reduce death and disease burden in HF have been suboptimally implemented. Approaches to closing care gaps have focused largely on strategies proven to be ineffective, whilst effective interventions shown to improve GDMT uptake have not been instituted. This review synthesizes implementation interventions that increase the uptake of GDMT, discusses barriers and facilitators of implementation, summarizes conceptual frameworks in implementation science that could improve knowledge uptake, and offers suggestions for trial design that could better facilitate end-of-trial implementation. We propose an evidence-to-care conceptual model that could foster the simultaneous generation of evidence and long-term implementation. By adopting principles of implementation science, policymakers, researchers, and clinicians can help reduce the burden of HF on patients and health care systems worldwide.
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Affiliation(s)
- Mohamed B Jalloh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tauben Averbuch
- Department of Cardiology, University of Calgary, Calgary Alberta, Canada
| | | | - Christopher B Granger
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - James L Januzzi
- Baim Institute for Clinical Research, Boston, Massachusetts, USA; Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Faiez Zannad
- Université de Lorraine, INSERM and Centre Hospitalier Régional Universitaire, Nancy, France
| | - Robert W Yeh
- Baim Institute for Clinical Research, Boston, Massachusetts, USA; Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Clyde W Yancy
- Baim Institute for Clinical Research, Boston, Massachusetts, USA; Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Indiana University, Indianapolis, Indiana, USA
| | - C Michael Gibson
- Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Harriette G C Van Spall
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Baim Institute for Clinical Research, Boston, Massachusetts, USA; Research Institute of St Joseph's, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.
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Fragasso G. Severe Left Ventricular Dysfunction After Acute Myocardial Infarction: A Call for Development of Adequately Targeted Treatments. Am J Cardiol 2023; 200:213-214. [PMID: 37385147 DOI: 10.1016/j.amjcard.2023.06.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 07/01/2023]
Affiliation(s)
- Gabriele Fragasso
- Heart Failure Clinic, Istituto Scientifico San Raffaele, Milano, Italy.
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10
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Boriani G, Venturelli A, Imberti JF, Bonini N, Mei DA, Vitolo M. Comparative analysis of level of evidence and class of recommendation for 50 clinical practice guidelines released by the European Society of Cardiology from 2011 to 2022. Eur J Intern Med 2023; 114:1-14. [PMID: 37169634 DOI: 10.1016/j.ejim.2023.04.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 04/11/2023] [Accepted: 04/22/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND The European Society of Cardiology (ESC) clinical practice guidelines are essential tools for decision-making. AIM To analyze the level of evidence (LOE) and the class of recommendations in the ESC guidelines released in the last 12 years. METHODS We evaluated 50 ESC guidelines released from 2011 to 2022, related to 27 topics and categorized them into seven macro-groups. We analyzed every recommendation in terms of LOE and class of recommendation, calculating their relative proportions and changes over time in consecutive editions of the same guideline. RESULTS A total of 6972 recommendations were found, with an increase in number per year over time. Among the 50 ESC guidelines, the proportional distribution of classes of recommendations was 49% for Class I, 29% for Class IIa, 15% for Class IIb, and 8% for Class III. Overall, 16% of the recommendations were classified as LOE A, 31% LOE B and 53% LOE C. The field of preventive cardiology had the largest proportion of LOE A, while the lowest was in the field of valvular, myocardial, pericardial and pulmonary diseases. The overall proportion of LOE A recommendations in the most recent guidelines compared to their prior versions increased from 17% to 20%. CONCLUSIONS The recommendations included in the ESC guidelines widely differ in terms of quality of evidence, with only 16% supported by the highest quality of evidence. Although a slight global increase in LOE A recommendations was observed in recent years, further scientific research efforts are needed to increase the quality of evidence.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, Modena 41124, Italy.
| | - Andrea Venturelli
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, Modena 41124, Italy
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, Modena 41124, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolò Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, Modena 41124, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Davide A Mei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, Modena 41124, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via del Pozzo, 71, Modena 41124, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
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Hirt J, Janiaud P, Düblin P, Hemkens LG. Meta-research on pragmatism of randomized trials: rationale and design of the PragMeta database. Trials 2023; 24:437. [PMID: 37391755 DOI: 10.1186/s13063-023-07474-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/24/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Pragmatic trials provide decision-oriented, real-world evidence that is highly applicable and generalizable. The interest in real-world evidence is fueled by the assumption that effects in the "real-world" are different to effects obtained under artificial, controlled, research conditions as often used for traditional explanatory trials. However, it is unknown which features of pragmatism, generalizability, and applicability would be responsible for such differences. There is a need to provide empirical evidence and promote meta-research to answer these fundamental questions on the pragmatism of randomized trials and real-world evidence. Here, we describe the rationale and design of the PragMeta database which pursues this goal ( www.PragMeta.org ). METHODS PragMeta is a non-commercial, open data platform and infrastructure to facilitate research on pragmatic trials. It collects and shares data from published randomized trials that either have a specific design feature or other characteristic related to pragmatism or they form clusters of trials addressing the same research question but having different aspects of pragmatism. This lays the foundation to determine the relationship of various features of pragmatism, generalizability, and applicability with intervention effects or other trial characteristics. The database contains trial data actively collected for PragMeta but also allows to import and link existing datasets of trials collected for other purposes, forming a large-scale meta-database. PragMeta captures data on (1) trial and design characteristics (e.g., sample size, population, intervention/comparison, outcome, longitudinal structure, blinding), (2) effects estimates, and (3) various determinants of pragmatism (e.g., the use of routinely collected data) and ratings from established tools used to determine pragmatism (e.g., the PRagmatic-Explanatory Continuum Indicator Summary 2; PRECIS-2). PragMeta is continuously provided online, inviting the meta-research community to collaborate, contribute, and/or use the database. As of April 2023, PragMeta contains data from > 700 trials, mostly with assessments on pragmatism. CONCLUSIONS PragMeta will inform a better understanding of pragmatism and the generation and interpretation of real-world evidence.
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Affiliation(s)
- Julian Hirt
- Pragmatic Evidence Lab, Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Spitalstrasse 2, Basel, CH-4031, Switzerland
- Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Health, Institute of Nursing Science, Eastern Switzerland University of Applied Sciences, St.Gallen, Switzerland
| | - Perrine Janiaud
- Pragmatic Evidence Lab, Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Spitalstrasse 2, Basel, CH-4031, Switzerland
- Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Pascal Düblin
- Pragmatic Evidence Lab, Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Spitalstrasse 2, Basel, CH-4031, Switzerland
| | - Lars G Hemkens
- Pragmatic Evidence Lab, Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Spitalstrasse 2, Basel, CH-4031, Switzerland.
- Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland.
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA.
- Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany.
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12
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Goyal P, Nanna MG. Stable Coronary Artery Disease in the Age of Geriatric Cardiology. J Am Coll Cardiol 2023; 81:1710-1713. [PMID: 37100487 PMCID: PMC10395647 DOI: 10.1016/j.jacc.2023.03.378] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 04/28/2023]
Affiliation(s)
- Parag Goyal
- Program for the Care and Study of the Aging Heart, Division of Cardiology, Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA.
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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13
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Chu CD, Lenoir KM, Rai NK, Soman S, Dwyer JP, Rocco MV, Agarwal AK, Beddhu S, Powell JR, Suarez MM, Lash JP, McWilliams A, Whelton PK, Drawz PE, Pajewski NM, Ishani A, Tuot DS. Concordance between clinical outcomes in the Systolic Blood Pressure Intervention Trial and in the electronic health record. Contemp Clin Trials 2023; 128:107172. [PMID: 37004812 PMCID: PMC10547257 DOI: 10.1016/j.cct.2023.107172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Randomized trials are the gold standard for generating clinical practice evidence, but follow-up and outcome ascertainment are resource-intensive. Electronic health record (EHR) data from routine care can be a cost-effective means of follow-up, but concordance with trial-ascertained outcomes is less well-studied. METHODS We linked EHR and trial data for participants of the Systolic Blood Pressure Intervention Trial (SPRINT), a randomized trial comparing intensive and standard blood pressure targets. Among participants with available EHR data concurrent to trial-ascertained outcomes, we calculated sensitivity, specificity, positive predictive value, and negative predictive value for EHR-recorded cardiovascular disease (CVD) events, using the gold standard of SPRINT-adjudicated outcomes (myocardial infarction (MI)/acute coronary syndrome (ACS), heart failure, stroke, and composite CVD events). We additionally compared the incidence of non-CVD adverse events (hyponatremia, hypernatremia, hypokalemia, hyperkalemia, bradycardia, and hypotension) in trial versus EHR data. RESULTS 2468 SPRINT participants were included (mean age 68 (SD 9) years; 26% female). EHR data demonstrated ≥80% sensitivity and specificity, and ≥ 99% negative predictive value for MI/ACS, heart failure, stroke, and composite CVD events. Positive predictive value ranged from 26% (95% CI; 16%, 38%) for heart failure to 52% (95% CI; 37%, 67%) for MI/ACS. EHR data uniformly identified more non-CVD adverse events and higher incidence rates compared with trial ascertainment. CONCLUSIONS These results support a role for EHR data collection in clinical trials, particularly for capturing laboratory-based adverse events. EHR data may be an efficient source for CVD outcome ascertainment, though there is clear benefit from adjudication to avoid false positives.
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Affiliation(s)
- Chi D Chu
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America.
| | - Kristin M Lenoir
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States of America
| | - Nayanjot Kaur Rai
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, United States of America
| | - Sandeep Soman
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, United States of America
| | - Jamie P Dwyer
- Division of Nephrology & Hypertension, University of Utah Health, Salt Lake City, UT, United States of America
| | - Michael V Rocco
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Anil K Agarwal
- Department of Medicine, Veterans Affairs Central California Health Care System, Fresno, CA, United States of America
| | - Srinivasan Beddhu
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - James R Powell
- Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, United States of America
| | - Maritza M Suarez
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - James P Lash
- Division of Nephrology, University of Illinois at Chicago, Chicago, IL, United States of America
| | - Andrew McWilliams
- Department of Internal Medicine, Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, United States of America
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, United States of America
| | - Paul E Drawz
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, United States of America
| | - Nicholas M Pajewski
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States of America
| | - Areef Ishani
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, United States of America
| | - Delphine S Tuot
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America
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14
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Klopf J, Willixhofer R, Scheuba A, Fuchs L, Sotir A, Wanhainen A, Brostjan C, Neumayer C, Eilenberg W. MetAAA trial patients show superior quality of life compared to patients under regular surveillance for small AAA: a single-center retrospective cohort study. Int J Surg 2023; 109:861-869. [PMID: 36999821 PMCID: PMC10389639 DOI: 10.1097/js9.0000000000000343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/07/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Abdominal aortic aneurysm (AAA) is a multifactorial vascular disease associated with high morbidity and mortality. Currently, surgical intervention is the only treatment option, and there is no drug therapy available for AAA. Hence, surveillance of AAA until indication for surgery may impact patient quality of life (QoL). There is a paucity of high-quality observational data on health status and QoL, particularly among AAA patients participating in randomized controlled trials. The objective of this study was to compare the QoL scores of AAA patients on surveillance to those of AAA patients enrolled in the MetAAA trial. MATERIAL AND METHODS Overall, 54 MetAAA trial patients and 23 AAA patients under regular surveillance for small AAA (part of a longitudinal monitoring study) were asked to complete three established and validated (in total 561 longitudinally collected) QoL questionnaires: the 36-Item Short Form Health Survey (SF-36), the Aneurysm Symptom Rating Questionnaire (ASRQ), and the Aneurysm-Dependent Quality of Life questionnaire (ADQoL). RESULTS A superior health status and QoL was found in AAA patients participating in the MetAAA trial compared to AAA patients under regular surveillance. In detail, MetAAA trial patients showed superior general health perception ( P =0.012), higher energy level ( P =0.036) as well as enhanced emotional well-being ( P =0.044) and fewer limitations due to general malaise ( P =0.021), which was subsequently reflected in an overall superior current QoL score ( P =0.039) compared to AAA patients under regular surveillance. CONCLUSION AAA patients enrolled in the MetAAA trial showed superior health status and QoL compared to AAA patients under regular surveillance.
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Affiliation(s)
- Johannes Klopf
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, University Hospital Vienna, Vienna, Austria
| | - Robin Willixhofer
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, University Hospital Vienna, Vienna, Austria
| | - Andreas Scheuba
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, University Hospital Vienna, Vienna, Austria
| | - Lukas Fuchs
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, University Hospital Vienna, Vienna, Austria
| | - Anna Sotir
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, University Hospital Vienna, Vienna, Austria
| | - Anders Wanhainen
- Department of Surgical Sciences, Uppsala University, Uppsala
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Christine Brostjan
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, University Hospital Vienna, Vienna, Austria
| | - Christoph Neumayer
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, University Hospital Vienna, Vienna, Austria
| | - Wolf Eilenberg
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, University Hospital Vienna, Vienna, Austria
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15
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Green MD, Dalmage MR, Lusk JB, Kadhim EF, Skalla LA, O'Brien EC. Public reporting of black participation in anti-hypertensive drug clinical trials. Am Heart J 2023; 258:129-139. [PMID: 36640861 DOI: 10.1016/j.ahj.2023.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/05/2022] [Accepted: 01/04/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Non-Hispanic Black people in the United States have the highest prevalence of essential hypertension. Unfortunately, clinical trials often underrepresent Black patients. We aim to understand whether trial sponsorship type is associated with representation of Black participants in anti-hypertensive drug clinical trials. Then, we contextualize our findings amongst current efforts to improve diversity in clinical research populations. METHODS We searched ClinicalTrials.gov in May 2022 for antihypertensive drug trials. Of n = 408 trials in our initial search, n = 97 (23.77%) met inclusion criteria and were stratified by sponsorship type (industry vs non-industry). Standardized tests of difference were employed to compare characteristics of these trials, and linear regression was used to model change over time. RESULTS Of 97 trials reporting results from 2010 to 2020, there were minimal differences in the percent of Black patients enrolled in anti-hypertensive clinical trials by sponsorship type. Both industry and non-industry sponsored studies had high rates of non-reporting, with slightly more non-reporting for industry (73.2%) vs non-industry (66.67%) studies. Industry funded studies reported results to ClinicalTrials.gov within 23.3 ± 15.0 months from completing studies, while non-industry funded trials reported within 18.9 ± 10.8 months. CONCLUSIONS Despite Black Americans carrying the highest burden of disease for essential hypertension, they are underrepresented in anti-hypertension clinical trials and their overall participation has decreased between 2010 and 2020. In addition, there is major underreporting of trial participant race. We implore researchers and funders to establish clear, meaningful targets for anti-hypertensive drug trial diversity, and improve transparency in reporting of study characteristics.
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Affiliation(s)
- Michael D Green
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America; Duke University Medical Center Library & Archives, Duke University School of Medicine, Durham, NC, United States of America.
| | - Mahalia R Dalmage
- Division of Biological Sciences, Pritzker School of Medicine, University of Chicago, Chicago, IL, United States of America
| | - Jay B Lusk
- Department of Neurology, Duke University School of Medicine, Durham, NC, United States of America; Fuqua School of Business, Duke University, Durham, NC, United States of America
| | - Emilie F Kadhim
- Social & Behavioural Health Sciences Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Lesley A Skalla
- Duke University Medical Center Library & Archives, Duke University School of Medicine, Durham, NC, United States of America
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
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16
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Washington V, Franklin JB, Huang ES, Mega JL, Abernethy AP. Diversity, Equity, and Inclusion in Clinical Research: A Path Toward Precision Health for Everyone. Clin Pharmacol Ther 2023; 113:575-584. [PMID: 36423203 DOI: 10.1002/cpt.2804] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/18/2022] [Indexed: 11/25/2022]
Abstract
Healthcare disparities are a persistent societal problem. One of the contributing factors to this status quo is the lack of diversity and representativeness of research efforts, which result in nongeneralizable evidence that, in turn, provides suboptimal means to enable the best possible outcomes at the individual level. There are several strategies that research teams can adopt to improve the diversity, equity, and inclusion (DEI) of their efforts; these strategies span the totality of the research path, from initial design to the shepherding of clinical data through a potential regulatory process. These strategies include more intentionality and DEI-based goal-setting, more diverse research and leadership teams, better community engagement to set study goals and approaches, better tailored outreach interventions, decentralization of study procedures and incorporation of innovative technology for more flexible data collection, and self-surveillance to identify and prevent biases. Within their remit of overlooking research efforts, regulatory authorities, as stakeholders, also have the potential for a positive effect on the DEI of emerging clinical evidence. All these are implementable tools and mechanisms that can make study participation more approachable to diverse communities, and ultimately generate evidence that is more generalizable and a conduit for better outcomes. The research community has an imperative to make DEI principles key foundational aspects in study conduct in order to pursue better personalized medicine for diverse patient populations.
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Affiliation(s)
| | | | - Erich S Huang
- Verily Life Sciences, South San Francisco, California, USA
| | - Jessica L Mega
- Verily Life Sciences, South San Francisco, California, USA
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Narang N, Nakamura M, Imamura T. Disparities in mechanical circulatory support utilization post cardiac arrest: An uncomfortable reality. Int J Cardiol 2023; 371:126-127. [PMID: 36216088 DOI: 10.1016/j.ijcard.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Affiliation(s)
| | - Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan.
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18
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Chen Q, Bowdish ME. The Cost of Internal Validity. Ann Thorac Surg 2023; 115:86-87. [PMID: 35793717 DOI: 10.1016/j.athoracsur.2022.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 06/17/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, 127 S San Vicente Blvd, AHSP-Ste A3600, Los Angeles, CA 90048
| | - Michael E Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars Sinai Medical Center, 127 S San Vicente Blvd, AHSP-Ste A3600, Los Angeles, CA 90048.
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Usman MS, Butler J, Khan MS. Pragmatism in clinical trials: essential, not optional. Eur Heart J 2022; 43:3285-3287. [PMID: 35938357 DOI: 10.1093/eurheartj/ehac400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, MS, USA.,Baylor Scott and White Research Institute, Dallas, TX, USA
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