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Kapp S, Gerdtz M, Gefen A, Padula W, Alves P, Trevellini C, Ghosh A, Shea A, Cross A, Sousa I, Santamaria N. Clinical and cost effectiveness of a system for turning and positioning intensive care unit patients, when compared to usual care turning and positioning devices, for the prevention of hospital-acquired pressure injuries. A randomised controlled trial. Int Wound J 2023; 20:3567-3579. [PMID: 37295778 PMCID: PMC10588344 DOI: 10.1111/iwj.14230] [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: 03/28/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 06/12/2023] Open
Abstract
Pressure injuries affect 13.1% to 45.5% of patients in the intensive care unit and lead to pain and discomfort for patients, burden on healthcare providers, and unnecessary cost to the health system. Turning and positioning systems offer improvements on usual care devices, however the evidence of the effectiveness of such systems is still emerging. We conducted an investigator initiated, prospective, single centre, two group, non-blinded, randomised controlled trial to determine the effectiveness of a system for turning and positioning intensive care unit patients, when compared to usual care turning and positioning devices, for preventing PIs. The trial was prematurely discontinued after enrolment of 78 participants due to COVID-19 pandemic related challenges and lower than expected enrolment rate. The study groups were comparable on baseline characteristics and adherence to the interventions was high. Four participants developed a PI (in the sacral, ischial tuberosity or buttock region), n = 2 each in the intervention and control group. Each participant developed one PI. As the trial is underpowered, these findings do not provide an indication of the clinical effectiveness of the interventions. There was no participant drop-out or withdrawal and there were no adverse events, device deficiencies, or adverse device effects identified or reported. The results of our study (in particular those pertaining to enrolment, intervention adherence and safety) provide considerations for future trials that seek to investigate how to prevent PIs among ICU patients.
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Affiliation(s)
- Suzanne Kapp
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne School of Health Sciences, Department of NursingThe University of MelbourneCarltonVictoriaAustralia
| | - Marie Gerdtz
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne School of Health Sciences, Department of NursingThe University of MelbourneCarltonVictoriaAustralia
| | - Amit Gefen
- The Herbert J. Berman Chair in Vascular Bioengineering, Department of Biomedical Engineering, Faculty of EngineeringTel Aviv UniversityTel AvivIsrael
| | - William Padula
- Department of Pharmaceutical & Health Economics, School of PharmacyUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
- University of Southern CaliforniaSchaeffer Center for Health Policy & EconomicsLos AngelesCaliforniaUSA
| | - Paulo Alves
- Universidade Católica Portuguesa, Center for interdisciplinary Research in Health (CIIS) ‐ Institute of Health SciencesPortoPortugal
| | | | - Angaj Ghosh
- The Northern HospitalEppingVictoriaAustralia
| | | | | | - Ines Sousa
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne School of Health Sciences, Department of NursingThe University of MelbourneCarltonVictoriaAustralia
| | - Nick Santamaria
- Faculty of Medicine, Dentistry and Health Sciences, Melbourne School of Health Sciences, Department of NursingThe University of MelbourneCarltonVictoriaAustralia
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2
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Agarwal A, Marion J, Nagy P, Robinson M, Walkey A, Sevransky J. How Electronic Medical Record Integration Can Support More Efficient Critical Care Clinical Trials. Crit Care Clin 2023; 39:733-749. [PMID: 37704337 DOI: 10.1016/j.ccc.2023.03.006] [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] [Indexed: 09/15/2023]
Abstract
Large volumes of data are collected on critically ill patients, and using data science to extract information from the electronic medical record (EMR) and to inform the design of clinical trials represents a new opportunity in critical care research. Using improved methods of phenotyping critical illnesses, subject identification and enrollment, and targeted treatment group assignment alongside newer trial designs such as adaptive platform trials can increase efficiency while lowering costs. Some tools such as the EMR to automate data collection are already in use. Refinement of data science approaches in critical illness research will allow for better clinical trials and, ultimately, improved patient outcomes.
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Affiliation(s)
- Ankita Agarwal
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA
| | | | - Paul Nagy
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew Robinson
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allan Walkey
- Department of Medicine - Section of Pulmonary, Allergy, Critical Care and Sleep Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Jonathan Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA.
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Morrell W, Gelinas L, Zarin D, Bierer BE. Ensuring the Scientific Value and Feasibility of Clinical Trials: A Qualitative Interview Study. AJOB Empir Bioeth 2023; 14:99-110. [PMID: 36599052 DOI: 10.1080/23294515.2022.2160510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Ethical and scientific principles require that clinical trials address an important question and have the resources needed to complete the study. However, there are no clear standards for review that would ensure that these principles are upheld. METHODS We conducted semi-structured interviews with a convenience sample of nineteen experts in clinical trial design, conduct, and/or oversight to elucidate current practice and identify areas of need with respect to ensuring the scientific value and feasibility of clinical trials prior to initiation and while ongoing. We used a priori and grounded theory to analyze the data and constant comparative method to induce higher order themes. RESULTS Interviewees perceived determination of scientific value as the responsibility of the investigator and, secondarily, other parties who review or oversee research. Interviewees reported that ongoing trials are rarely reevaluated due to emerging evidence from external sources, evaluation is complex, and there would be value in the development of standards for monitoring and evaluating evidence systematically. Investigators, IRBs, and/or data monitoring committees (DMCs) could undertake these responsibilities. Feasibility assessments are performed but are typically inadequate; potential solutions are unclear. CONCLUSIONS There are three domains where current approaches are suboptimal and in which further guidance is needed. First, who has the responsibility for conducting scientific review, whether it be the investigator, IRB, and/or DMC is often unclear. Second, the standards for scientific review (e.g., appropriate search terms, data sources, and analytic plan) should be defined. Third, guidance is needed on the evaluation of ongoing studies in light of potentially new and evolving evidence, with particular reference to evidence from outside the trial itself.
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Affiliation(s)
- Walker Morrell
- Multi-Regional Clinical Trials Center, Brigham & Women's Hospital and Harvard, Cambridge, MA, USA
| | - Luke Gelinas
- Multi-Regional Clinical Trials Center, Brigham & Women's Hospital and Harvard, Cambridge, MA, USA.,Advarra IRB, Columbia, MD, USA
| | - Deborah Zarin
- Multi-Regional Clinical Trials Center, Brigham & Women's Hospital and Harvard, Cambridge, MA, USA
| | - Barbara E Bierer
- Multi-Regional Clinical Trials Center, Brigham & Women's Hospital and Harvard, Cambridge, MA, USA.,Harvard Medical School, Boston, MA, USA.,Brigham & Women's Hospital, Boston, MA, USA
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Ramanan M, Kumar A, Billot L, Myburgh J, Venkatesh B. Recruitment characteristics of randomised trials in critical care: A systematic review. Clin Trials 2022; 19:673-680. [PMID: 36068946 DOI: 10.1177/17407745221123248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND/AIMS To summarise the temporal trends of recruitment and methodological characteristics of critical care randomised controlled trials with the primary outcome of mortality. METHODS PubMed was searched for articles meeting inclusion and exclusion criteria. Randomised controlled trials, with primary outcome of mortality, of adult and paediatric critical care patients treated in an intensive care unit, were included. Neonatal intensive care unit trials, non-English publications and conference proceedings or abstracts without full-length publications were excluded. Duplicate literature search, article selection and quality assessment were performed by two reviewers with disputes resolved through discussion. Data were extracted into a custom-designed Research Electronic Data Capture database. RESULTS The search identified 67,199 records of which 230 were included. The annual number of critical care randomised controlled trials published increased gradually over a 30-year period from 0 in 1990 to 19 in 2014 with stabilisation at 8-11 between 2015 and 2020. Twenty-seven percent of randomised controlled trials were low risk in all categories using the Cochrane Risk of Bias tool. Methodological characteristics such as registration on clinical trials registries and data safety monitoring committee presence significantly (p < 0.001) increased over time. The median recruitment was 376 patients (interquartile range 125-895) with significant increase (p = 0.002) from 62 (interquartile range: 33-486) in 1991 to 725 (interquartile range: 537-2600) in 2020. This was accompanied by an increase in recruitment times. Thus overall, recruitment rates did not increase. Early cessation occurred in 23% (54/230) of randomised controlled trials with no temporal trend. CONCLUSION The number, size and some methodological qualities of critical randomised controlled trials with primary outcome of mortality have increased over time, but rates of recruitment and early cessation have been unchanged.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Caboolture, QLD, Australia.,Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Aashish Kumar
- Intensive Care Unit, Logan Hospital, Meadowbrook, QLD, Australia
| | - Laurent Billot
- Statistics Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Balasubramanian Venkatesh
- School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.,Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.,Intensive Care Unit, Wesley Hospital, Auchenflower, QLD, Australia
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5
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Menzies JC, Jennings C, Marshall R. A Survey of Resources and Nursing Workforce for Clinical Research Delivery in Paediatric Intensive Care Within the UK / Ireland. Front Pediatr 2022; 10:848378. [PMID: 35586827 PMCID: PMC9108499 DOI: 10.3389/fped.2022.848378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/08/2022] [Indexed: 12/05/2022] Open
Abstract
Introduction Clinical research within Paediatric Intensive Care (PICU) is necessary to reduce morbidity and mortality associated within this resource-intensive environment. With UK PICUs encouraged to be research-active there was a drive to understand how centres support research delivery. Aim To identify the research workforce available within UK/Ireland PICUs to support clinical research delivery. Method An electronic survey, endorsed by the Paediatric Critical Care Society (PCCS), was designed and reported in accordance with CHERRIES guidelines. The survey was distributed by email to all UK/Ireland Nurse Managers and Medical/ Nursing Research leads, aiming for one response per site during the period of April-June 2021. Only one response per site was included in analysis. Results 44 responses were received, representing 24/30 UK/Ireland sites (80% response rate). Responses from n = 21/30 units are included (three excluded for insufficient data). 90% (n = 19/21) units were research active, although only 52% (n = 11) had permanent research roles funded within their staffing establishment. The majority of units (n = 18, 86%) had less than two WTE research nurses. Resources were felt to be sufficient for current research delivery by 43% of units (n = 9), but this confidence diminished to 19% (n = 4) when considering their ability to support future research. The top barriers to research conduct were insufficiently funded/unfunded studies (52%; n = 11), clinical staff too busy to support research activity (52%; n = 11) and short-term/fixed-term contracts for research staff (38%; n = 8). Conclusion Despite the perceived importance of research and 90% of responding UK/Ireland PICUs being research active, the majority have limited resources to support research delivery. This has implications for their ability to participate in future multi-centre trials and opportunities to support the development of future medical/nursing clinical academics. Further work is required to identify optimum models of clinical research delivery.
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Affiliation(s)
- Julie C. Menzies
- Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
- College of Medical and Dental Sciences, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Claire Jennings
- Paediatric Critical Care Unit, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Rebecca Marshall
- Paediatric Critical Care Unit, Royal Manchester Children's Hospital, Manchester, United Kingdom
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6
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Barnett AG, Glasziou P. Target and actual sample sizes for studies from two trial registries from 1999 to 2020: an observational study. BMJ Open 2021. [PMCID: PMC8719224 DOI: 10.1136/bmjopen-2021-053377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objectives To investigate differences between target and actual sample sizes, and what study characteristics were associated with sample sizes. Design Observational study. Setting The large trial registries of clinicaltrials.gov (starting in 1999) and ANZCTR (starting in 2005) through to 2021. Participants Over 280 000 interventional studies excluding studies that were withheld, terminated for safety reasons or were expanded access. Main outcome measures The actual and target sample sizes, and the within-study ratio of the actual to target sample size. Results Most studies were small: the median actual sample sizes in the two databases were 60 and 52. There was a decrease over time in the target sample size of 9%–10% per 5 years, and a larger decrease of 18%–21% per 5 years for the actual sample size. The actual-to-target sample size ratio was 4.1% lower per 5 years, meaning more studies (on average) failed to hit their target sample size. Conclusion Registered studies are more often under-recruited than over-recruited and worryingly both target and actual sample sizes appear to have decreased over time, as has the within-study gap between the target and actual sample size. Declining sample sizes and ongoing concerns about underpowered studies mean more research is needed into barriers and facilitators for improving recruitment and accessing data.
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Affiliation(s)
- Adrian Gerard Barnett
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Paul Glasziou
- CREBP, Bond University, Robina, Queensland, Australia
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Roquet F, Pirracchio R. One- versus two-sided statistical tests: A never-ending debate. Anaesth Crit Care Pain Med 2021; 40:100980. [PMID: 34763142 DOI: 10.1016/j.accpm.2021.100980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Florian Roquet
- Département d'Anesthésie Réanimation, Assistance Publique-Hôpitaux de Paris, HEGP, Université de Paris, Paris, France; INSERM UMR 1153, Université de Paris, Paris, France
| | - Romain Pirracchio
- Département d'Anesthésie Réanimation, Assistance Publique-Hôpitaux de Paris, HEGP, Université de Paris, Paris, France; Department of Anesthesia and Perioperative Medicine, University of California, San Francisco, CA, USA.
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Paddock K, Woolfall K, Frith L, Watkins M, Gamble C, Welters I, Young B. Strategies to enhance recruitment and consent to intensive care studies: a qualitative study with researchers and patient-public involvement contributors. BMJ Open 2021; 11:e048193. [PMID: 34551943 PMCID: PMC8461270 DOI: 10.1136/bmjopen-2020-048193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Clinical trials and studies in intensive care units (ICUs) have complex consent processes and often encounter problems in recruiting patients. By interviewing research team members about the challenges in critical care research, we aimed to identify strategies to enhance recruitment and consent to ICU studies. METHODS Semistructured interviews with UK-based researchers (N=17) and patient-public involvement (PPI) contributors (N=8) with experience of ICU studies. Analysis of transcripts of audio-recorded interviews drew on thematic approaches. RESULTS Seven themes were identified. Participants emphasised the need for substitute decision-making processes in critical care studies, yet some researchers reported that research ethics committees (RECs) were reluctant to approve such processes. Researchers spoke about the potential benefits of research without prior consent (RWPC) for studies with narrow recruitment windows but believed RECs would not approve them. Participants indicated that the activity of PPI contributors was limited in critical care studies, though researchers who had involved PPI contributors more extensively were clear that their input when designing consent processes was important. Researchers and PPI contributors pointed to resource and staffing limitations as barriers to patient recruitment. Researchers varied in whether and how they used professional consultees as substitute decision-makers, in whether they approached families by telephone to discuss research and in whether they disclosed details of research participation to bereaved relatives. CONCLUSION Critical care research could benefit from RECs having expertise in consent processes that are suited to this setting, better staffing at research sites, more extensive PPI and an evidence base on stakeholder perspectives on critical care research processes. Guidance on professional consultee processes, telephoning relatives to discuss research, RWPC and disclosure of research participation to bereaved relatives could help to harmonise practice in these areas and enhance recruitment and consent to critical care studies.
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Affiliation(s)
- Katie Paddock
- Faculty of Health and Education, School of Childhood, Youth and Education Studies, Manchester Metropolitan University, Manchester, UK
- Institute of Population Health, Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Kerry Woolfall
- Institute of Population Health, Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Lucy Frith
- Faculty of Humanities and Social Sciences, Department of Law and Philosophy, University of Liverpool, Liverpool, UK
| | - Megan Watkins
- Institute of Population Health, Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Carrol Gamble
- Institute of Population Health, Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Ingeborg Welters
- Institute of Life Course and Medical Science, University of Liverpool, Liverpool, UK
- Department of Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Bridget Young
- Institute of Population Health, Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
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Knisley L, Le A, Scott SD. An online survey to assess parents' preferences for learning about child health research. Nurs Open 2021; 8:3143-3151. [PMID: 34390222 PMCID: PMC8510747 DOI: 10.1002/nop2.1027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/07/2021] [Accepted: 07/25/2021] [Indexed: 11/11/2022] Open
Abstract
Aim Ethical and logistical issues often exacerbate recruitment problems in child health studies. This study aims: (a) to provide new knowledge on how parents want to hear about child health research and (b) to inform the KidsCAN PERC iPCT initiative's re‐examination of recruitment and retention strategies for pediatric emergency department research studies. Design We employed a cross‐sectional, survey design. Methods An online survey was distributed to participants (i.e., parents) through partner organizations' advisory group mailing lists. Frequencies and measures of central tendency guided data analysis. Results Parents are interested in hearing about child health research opportunities, particularly during general practitioner, pediatrician or walk‐in clinic visits. Most parents wanted updates on the research team, progress and results and support to participate, such as reimbursement of travel and childcare costs. Results can inform research teams in the planning of communications to effectively share research opportunities, progress and results with parents.
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Affiliation(s)
- Lisa Knisley
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Anne Le
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Shannon D Scott
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
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10
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Coyer F, Campbell J, Doubrovsky A. Efficacy of Incontinence-Associated Dermatitis Intervention for Patients in Intensive Care: An Open-Label Pilot Randomized Controlled Trial. Adv Skin Wound Care 2021; 33:375-382. [PMID: 32544117 DOI: 10.1097/01.asw.0000666904.35944.a3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the feasibility of an adequately powered trial testing a long-acting cyanoacrylate skin protectant to prevent incontinence-associated dermatitis in critically ill patients. METHODS This open-label pilot randomized controlled feasibility study was conducted in the adult ICU of an Australian quaternary referral hospital. Patients were allocated to either an intervention group or a control group (usual care). The intervention was the application of a skin protectant (a durable, ultra-thin, transparent, waterproof, no-removal barrier film). Data collected by trained research nurses included demographic and clinical variables, skin assessment, and incontinence-associated dermatitis presence and severity. Data were analyzed using descriptive and inferential statistics. RESULTS Of the 799 patients screened, 85% were eliminated because of a short ICU stay or other exclusion criteria. The mean proportion of patients not meeting any of the exclusion criteria was 22% on each screening day. Protocol fidelity was followed for 90% of intervention participant study days. Retention of participants was 86% (31 participants out of 36), 15 in the intervention group and 16 in the control group. Enrolled patients had a mean age of 59 years, 50% were obese, 67% were male, and 36% were smokers. Two patients (11%) in the intervention group developed incontinence-associated dermatitis, compared with three (17%) in the control group. CONCLUSIONS This study reports no significant findings between the two groups. Difficulty in recruitment and feasibility issues might be overcome with changes to inclusion criteria and study design.
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Affiliation(s)
- Fiona Coyer
- At the Queensland University of Technology in Brisbane, Queensland, Australia, Fiona Coyer, PhD, MSc, RN, is Professor of Nursing, Joint Appointment Intensive Care Services, Royal Brisbane and Women's Hospital and School of Nursing; Jill Campbell, PhD, RN, Grad Dip (Wound Care), is Visiting Fellow, School of Nursing; and Anna Doubrovsky, MPH, BSc (Hons), is Data Analyst and Research Assistant, School of Nursing. Acknowledgments: The authors thank the research nurses (Fiona Boch and Stacey Watts) and all patients who participated. The study was sponsored by 3M, which provided funding for research assistants, the investigational product, and training to two authors on the product application. The authors have disclosed no other financial relationships related to this article. Submitted May 20, 2019; accepted in revised form August 29, 2019
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11
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Tracey M, Finkelstein Y, Schachter R, Cleverley K, Monga S, Barwick M, Szatmari P, Moretti ME, Willan A, Henderson J, Korczak DJ. Recruitment of adolescents with suicidal ideation in the emergency department: lessons from a randomized controlled pilot trial of a youth suicide prevention intervention. BMC Med Res Methodol 2020; 20:231. [PMID: 32928140 PMCID: PMC7490899 DOI: 10.1186/s12874-020-01117-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergency Departments (EDs) are a first point-of-contact for many youth with mental health and suicidality concerns and can serve as an effective recruitment source for randomized controlled trials (RCTs) of mental health interventions. However, recruitment in acute care settings is impeded by several challenges. This pilot RCT of a youth suicide prevention intervention recruited adolescents aged 12 to 17 years presenting to a pediatric hospital ED with suicide related behaviors. METHODS Recruitment barriers were identified during the initial study recruitment period and included: the time of day of ED presentations, challenges inherent to study presentation, engagement and participation during an acute presentation, challenges approaching and enrolling acutely suicidal patients and families, ED environmental factors, and youth and parental concerns regarding the study. We calculated the average recruitment productivity for published trials of adolescent suicide prevention strategies which included the ED as a recruitment site in order to compare our recruitment productivity. RESULTS In response to identified barriers, an enhanced ED-centered recruitment strategy was developed to address low recruitment rate, specifically (i) engaging a wider network of ED and outpatient psychiatry staff (ii) dissemination of study pamphlets across multiple areas of the ED and relevant outpatient clinics. Following implementation of the enhanced recruitment strategy, the pre-post recruitment productivity, a ratio of patients screened to patients randomized, was computed. A total of 120 patients were approached for participation, 89 (74.2%) were screened and 45 (37.5%) were consented for the study from March 2018 to April 2019. The screening to randomization ratio for the study period prior to the introduction of the enhanced recruitment strategies was 3:1, which decreased to 1.8:1 following the implementation of enhanced recruitment strategies. The ratio for the total recruitment period was 2.1:1. This was lower than the average ratio of 3.2:1 for published trials. CONCLUSIONS EDs are feasible sites for participant recruitment in RCTs examining new interventions for acute mental health problems, including suicidality. Engaging multi-disciplinary ED staff to support recruitment for such studies, proactively addressing anticipated concerns, and creating a robust recruitment pathway that includes approach at outpatient appointments can optimize recruitment. TRIAL REGISTRATION ClinicalTrials.gov : NCT03488602 , retrospectively registered April 4, 2018.
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Affiliation(s)
- Matthew Tracey
- Department of Psychiatry, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Yaron Finkelstein
- Divisions of Paediatric Emergency Medicine and Clinical Pharmacology and Toxicology, Hospital for Sick Children, 525 University Avenue, Toronto, ON, M5G 2L3, Canada
| | - Reva Schachter
- Department of Psychiatry, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Kristin Cleverley
- Lawrence S. Bloomberg Faculty of Nursing and Department of Psychiatry, University of Toronto, 130-155 College Street, Toronto, ON, M5P 1T8, Canada
| | - Suneeta Monga
- Department of Psychiatry, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Department of Psychiatry, University of Toronto, 250 College St, Toronto, ON, M5T 1R8, Canada
| | - Melanie Barwick
- Department of Psychiatry, University of Toronto, 250 College St, Toronto, ON, M5T 1R8, Canada.,Research Institute, Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada
| | - Peter Szatmari
- Department of Psychiatry, University of Toronto, 250 College St, Toronto, ON, M5T 1R8, Canada
| | - Myla E Moretti
- Clinical Trial Unit, Ontario Child Health Support Unit, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Andrew Willan
- Clinical Trial Unit, Ontario Child Health Support Unit, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Joanna Henderson
- Centre for Addiction and Mental Health, 5226-88 Workman Way, Toronto, ON, M5J 1H4, Canada
| | - Daphne J Korczak
- Department of Psychiatry, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Research Institute, Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 0A4, Canada.
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12
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Shepherd V. Advances and challenges in conducting ethical trials involving populations lacking capacity to consent: A decade in review. Contemp Clin Trials 2020; 95:106054. [PMID: 32526281 PMCID: PMC7832147 DOI: 10.1016/j.cct.2020.106054] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/21/2020] [Accepted: 06/03/2020] [Indexed: 01/28/2023]
Abstract
Informed consent is an essential requirement prior to clinical trial participation, however some 'vulnerable' groups, such as people with cognitive impairments and those in medical emergency situations, may lack decisional capacity to consent. This raises ethical and practical challenges when designing and conducting clinical trials involving these populations, who are frequently excluded as a result. Despite recent advances in improving informed consent processes, there has been far less attention paid to the enrolment of adults lacking capacity. Exclusion criteria are an important determinant of the external validity of clinical trial results. The exclusion of these populations, and consent-based recruitment biases which arise from the challenges of identifying and involving surrogate decision-makers, leads to trials which are not representative of the clinical population. This article discusses the involvement of adults who lack decisional capacity to consent in clinical trials and presents the advances over the previous decade and the remaining ethical challenges for the inclusion of this under-represented population in research.
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Affiliation(s)
- Victoria Shepherd
- Centre for Trials Research, 4th floor Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS, UK.
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13
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Coyer F, Cook JL, Brown W, Vann A, Doubrovsky A. Securement to prevent device-related pressure injuries in the intensive care unit: A randomised controlled feasibility study. Int Wound J 2020; 17:1566-1577. [PMID: 32596937 DOI: 10.1111/iwj.13432] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 12/13/2022] Open
Abstract
Medical device-related pressure injuries are the most common cause of pressure injuries within the intensive care unit, in particular those caused by nasogastric tubes and endotracheal tubes. There are several known methods, which can alleviate the pressure of these devices on the skin surface to reduce the rate of these injuries. To determine the feasibility of conducting a larger, adequately powered trial testing, several clinically effective interventions to reduce the incidence of medical device-related pressure injuries caused by these devices. Patients were recruited into both study arms and received one of three different methods of skin protection for both arms. Outcome measures included fidelity to the processes of care protocol, recruitment potential, and the number of medical device-related pressure injuries. Recruitment (n = 87) was slower than expected with less than 10% of screened potential patients available for enrolment. Fidelity to the process of care for each subgroup was variable with better adherence in the nasogastric tube arm compared to the endotracheal tube arm. This feasibility study has revealed concerns about the intervention designs and effectiveness as well as challenges for the adherence of the nursing staff to the protocol.
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Affiliation(s)
- Fiona Coyer
- Joint appointment Intensive Care Services, Royal Brisbane and Women's Hospital and School of Nursing, Queensland University of Technology, Australia.,Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield, UK
| | - Jane-Louise Cook
- School of Nursing, Queensland University of Technology, Brisbane, Australia
| | - Wendy Brown
- Department of Intensive Care, Redcliffe Hospital, Redcliffe, Australia
| | - Amanda Vann
- Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Anna Doubrovsky
- School of Nursing, Queensland University of Technology, Brisbane, Australia
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14
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Lambrichts DPV, van Dieren S, Bemelman WA, Lange JF. Cost-effectiveness of sigmoid resection with primary anastomosis or end colostomy for perforated diverticulitis: an analysis of the randomized Ladies trial. Br J Surg 2020; 107:1686-1694. [PMID: 32521053 PMCID: PMC7687276 DOI: 10.1002/bjs.11715] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 03/11/2020] [Accepted: 04/29/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Several studies have been published favouring sigmoidectomy with primary anastomosis over Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis (Hinchey grade III or IV), but cost-related outcomes were rarely reported. The present study aimed to evaluate costs and cost-effectiveness within the DIVA arm of the Ladies trial. METHODS This was a cost-effectiveness analysis of the DIVA arm of the multicentre randomized Ladies trial, comparing primary anastomosis over Hartmann's procedure for Hinchey grade III or IV diverticulitis. During 12-month follow-up, data on resource use, indirect costs (Short Form Health and Labour Questionnaire) and quality of life (EuroQol Five Dimensions) were collected prospectively, and analysed according to the modified intention-to-treat principle. Main outcomes were incremental cost-effectiveness (ICER) and cost-utility (ICUR) ratios, expressed as the ratio of incremental costs and the incremental probability of being stoma-free or incremental quality-adjusted life-years respectively. RESULTS Overall, 130 patients were included, of whom 64 were allocated to primary anastomosis (46 and 18 with Hinchey III and IV disease respectively) and 66 to Hartmann's procedure (46 and 20 respectively). Overall mean costs per patient were lower for primary anastomosis (€20 544, 95 per cent c.i. 19 569 to 21 519) than Hartmann's procedure (€28 670, 26 636 to 30 704), with a mean difference of €-8126 (-14 660 to -1592). The ICER was €-39 094 (95 per cent bias-corrected and accelerated (BCa) c.i. -1213 to -116), indicating primary anastomosis to be more cost-effective. The ICUR was €-101 435 (BCa c.i. -1 113 264 to 251 840). CONCLUSION Primary anastomosis is more cost-effective than Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis.
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Affiliation(s)
- D P V Lambrichts
- Departments of Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands.,Amsterdam University Medical Centre, AMC, Amsterdam, the Netherlands
| | - S van Dieren
- Amsterdam University Medical Centre, AMC, Amsterdam, the Netherlands
| | - W A Bemelman
- Amsterdam University Medical Centre, AMC, Amsterdam, the Netherlands
| | - J F Lange
- Departments of Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands.,IJsselland Hospital, Capelle aan den IJssel, the Netherlands
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15
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Ramanan M, Billot L, Rajbhandari D, Myburgh J, Finfer S, Bellomo R, Venkatesh B. Does asymmetry in patient recruitment in large critical care trials follow the Pareto principle? Trials 2020; 21:378. [PMID: 32370789 PMCID: PMC7201735 DOI: 10.1186/s13063-020-04279-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 03/24/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Randomised controlled trials (RCT) may be hindered by slow recruitment rates, particularly in critically ill patients. While statistical models to predict recruitment rates have been described, no systematic assessment has been conducted of the distribution of recruitment across sites, temporal trends in site participation and impact of competing trials on patient recruitment. METHODS We used recruitment and screening logs from the SAFE, NICE-SUGAR, RENAL, CHEST and ADRENAL trials, five of the largest critical care RCTs. We quantified the extent of recruitment asymmetry between sites using Lorenz curves and Gini coefficients and assessed whether the recruitment distribution across sites follow the Pareto principle, which states that 80% of effects come from 20% of causes. Peak recruitment rates and growth in participating sites were calculated. RESULTS In total, 25,412 patients were randomised in 99 intensive care units (ICUs) for the five trials. Distribution of recruitment was asymmetric, with a small number of ICUs recruiting a large proportion of the patients. The Gini coefficients ranged from 0.14 to 0.52. The time to peak recruitment rate ranged from 7 to 41 months and was variable (7, 31, 41, 10 and 40 months). Over time, the proportion of recruitment at non-tertiary ICUs increased from 15% to 34%. CONCLUSIONS There is asymmetry of recruitment with a small proportion of ICUs recruiting a large proportion of patients. The distributions of recruitment were not consistent with the Pareto principle. There has been increasing participation of non-tertiary ICUs in clinical trials.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture and The Prince Charles Hospitals, Brisbane, Australia.
- University of Queensland, Brisbane, Australia.
- Critical Care Division, The George Institute for Global Health, Sydney, Australia.
| | - Laurent Billot
- Statistics Division, The George Institute for Global Health, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | - Dorrilyn Rajbhandari
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | - Simon Finfer
- University of Sydney, Sydney, Australia
- Intensive Care Unit, Sydney Adventist Hospital, Sydney, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Australia New Zealand Intensive Care Research Centre, Melbourne, Australia
| | - Balasubramanian Venkatesh
- University of Queensland, Brisbane, Australia
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Intensive Care Unit, Wesley Hospital, Brisbane, Australia
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Australia
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16
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Lambrichts DPV, Edomskis PP, van der Bogt RD, Kleinrensink GJ, Bemelman WA, Lange JF. Sigmoid resection with primary anastomosis versus the Hartmann's procedure for perforated diverticulitis with purulent or fecal peritonitis: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:1371-1386. [PMID: 32504331 PMCID: PMC7340681 DOI: 10.1007/s00384-020-03617-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE The optimal surgical approach for perforated diverticulitis with purulent or fecal peritonitis (Hinchey grade III or IV) remains debated. In recent years, accumulating evidence comparing sigmoid resection with primary anastomosis (PA) with the Hartmann's procedure (HP) was presented. Therefore, the aim was to provide an updated and extensive synthesis of the available evidence. METHODS A systematic search in Embase, MEDLINE, Cochrane, and Web of Science databases was performed. Studies comparing PA to HP for adult patients with Hinchey III or IV diverticulitis were included. Data on mortality, morbidity, stoma reversal, and patient-reported and cost-related outcomes were extracted. Random effects models were used to pool data and estimate odds ratios (ORs). RESULTS From a total of 1560 articles, four randomized controlled trials and ten observational studies were identified, reporting on 1066 Hinchey III/IV patients. Based on trial outcomes, PA was found to be favorable over HP in terms of stoma reversal rates (OR 2.62, 95% CI 1.29, 5.31) and reversal-related morbidity (OR 0.33, 95% CI 0.16, 0.69). No differences in mortality (OR 0.83, 95% CI 0.32, 2.19), morbidity (OR 0.99, 95% CI 0.65, 1.51), and reintervention rates (OR 0.90, 95% CI 0.39, 2.11) after the index procedure were demonstrated. Data on patient-reported and cost-related outcomes were scarce, as well as outcomes in PA patients with or without ileostomy construction and Hinchey IV patients. CONCLUSION Although between-study heterogeneity needs to be taken into account, the present results indicate that primary anastomosis seems to be the preferred option over Hartmann's procedure in selected patients with Hinchey III or IV diverticulitis.
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Affiliation(s)
- Daniël PV Lambrichts
- Department of Surgery, Erasmus University Medical Center, Rotterdam, 3015 GD The Netherlands ,Department of Surgery, Amsterdam University Medical Center, AMC, Amsterdam, The Netherlands
| | - Pim P Edomskis
- Department of Surgery, Erasmus University Medical Center, Rotterdam, 3015 GD The Netherlands
| | - Ruben D van der Bogt
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gert-Jan Kleinrensink
- Department of Neuroscience, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Willem A Bemelman
- Department of Surgery, Amsterdam University Medical Center, AMC, Amsterdam, The Netherlands
| | - Johan F Lange
- Department of Surgery, Erasmus University Medical Center, Rotterdam, 3015 GD The Netherlands ,Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
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17
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Briel M, Speich B, von Elm E, Gloy V. Comparison of randomized controlled trials discontinued or revised for poor recruitment and completed trials with the same research question: a matched qualitative study. Trials 2019; 20:800. [PMID: 31888725 PMCID: PMC6937940 DOI: 10.1186/s13063-019-3957-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 12/04/2019] [Indexed: 01/25/2023] Open
Abstract
Background More than a quarter of randomized controlled trials (RCTs) are prematurely discontinued, mostly due to poor recruitment of patients. In this study, we systematically compared RCTs discontinued or revised for poor recruitment and completed RCTs with the same underlying research question to better understand the causes of poor recruitment, particularly related to methodological aspects and context-specific study settings. Methods We compared RCTs that were discontinued or revised for poor recruitment to RCTs that were completed as planned, matching in terms of population and intervention. Based on an existing sample of RCTs discontinued or revised due to poor recruitment, we identified matching RCTs through a literature search for systematic reviews that cited the discontinued or revised RCT and matching completed RCTs without poor recruitment. Based on extracted data, we explored differences in the design, conduct, and study settings between RCTs with and without poor recruitment, separately for each research question using semi-structured discussions. Results We identified 15 separate research questions with a total of 29 RCTs discontinued or revised for poor recruitment and 48 RCTs completed as planned. Prominent research areas in the sample were cancer and acute care. The mean number of RCTs with poor recruitment per research question was 1.9 ranging from 1 to 4 suggesting clusters of research questions or settings prone to recruitment problems. The reporting quality of the recruitment process in RCT publications was generally low. We found that RCTs with poor recruitment often had narrower eligibility criteria, were investigator- rather than industry-sponsored, were associated with a higher burden for patients and recruiters, sometimes used outdated control interventions, and were often launched later in time than RCTs without poor recruitment compromising uncertainty about tested interventions through emerging evidence. Whether a multi- or single-center setting was advantageous for patient recruitment seemed to depend on the research context. Conclusions Our study confirmed previously identified causes for poor recruitment, i.e., narrow eligibility criteria, investigator sponsorship, and a reduced motivation of patients and recruiters. Newly identified aspects were that researchers need to be aware of all other RCTs on a research question so that compromising effects on the recruitment can be minimized and that a larger number of centers is not always advantageous.
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Affiliation(s)
- Matthias Briel
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Benjamin Speich
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Erik von Elm
- Cochrane Switzerland, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Viktoria Gloy
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
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18
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Hartmann's procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or faecal peritonitis (LADIES): a multicentre, parallel-group, randomised, open-label, superiority trial. Lancet Gastroenterol Hepatol 2019; 4:599-610. [PMID: 31178342 DOI: 10.1016/s2468-1253(19)30174-8] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/15/2019] [Accepted: 03/18/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Previous studies have suggested that sigmoidectomy with primary anastomosis is superior to Hartmann's procedure. The likelihood of stoma reversal after primary anastomosis has been reported to be higher and reversal seems to be associated with lower morbidity and mortality. Although promising, results from these previous studies remain uncertain because of potential selection bias. Therefore, this study aimed to assess outcomes after Hartmann's procedure versus sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy, for perforated diverticulitis with purulent or faecal peritonitis (Hinchey III or IV disease) in a randomised trial. METHODS A multicentre, randomised, open-label, superiority trial was done in eight academic hospitals and 34 teaching hospitals in Belgium, Italy, and the Netherlands. Patients aged between 18 and 85 years who presented with clinical signs of general peritonitis and suspected perforated diverticulitis were eligible for inclusion if plain abdominal radiography or CT scan showed diffuse free air or fluid. Patients with Hinchey I or II diverticulitis were not eligible for inclusion. Patients were allocated (1:1) to Hartmann's procedure or sigmoidectomy with primary anastomosis, with or without defunctioning ileostomy. Patients were enrolled by the surgeon or surgical resident involved, and secure online randomisation software was used in the operating room or by the trial coordinator on the phone. Random and concealed block sizes of two, four, or six were used, and randomisation was stratified by age (<60 and ≥60 years). The primary endpoint was 12-month stoma-free survival. Patients were analysed according to a modified intention-to-treat principle. The trial is registered with the Netherlands Trial Register, number NTR2037, and ClinicalTrials.gov, number NCT01317485. FINDINGS Between July 1, 2010, and Feb 22, 2013, and June 9, 2013, and trial termination on June 3, 2016, 133 patients (93 with Hinchey III disease and 40 with Hinchey IV disease) were randomly assigned to Hartmann's procedure (68 patients) or primary anastomosis (65 patients). Two patients in the Hartmann's group were excluded, as was one in the primary anastomosis group; the modified intention-to-treat population therefore consisted of 66 patients in the Hartmann's procedure group (46 with Hinchey III disease, 20 with Hinchey IV disease) and 64 in the primary anastomosis group (46 with Hinchey III disease, 18 with Hinchey IV disease). In 17 (27%) of 64 patients assigned to primary anastomosis, no stoma was constructed. 12-month stoma-free survival was significantly better for patients undergoing primary anastomosis compared with Hartmann's procedure (94·6% [95% CI 88·7-100] vs 71·7% [95% CI 60·1-83·3], hazard ratio 2·79 [95% CI 1·86-4·18]; log-rank p<0·0001). There were no significant differences in short-term morbidity and mortality after the index procedure for Hartmann's procedure compared with primary anastomosis (morbidity: 29 [44%] of 66 patients vs 25 [39%] of 64, p=0·60; mortality: two [3%] vs four [6%], p=0·44). INTERPRETATION In haemodynamically stable, immunocompetent patients younger than 85 years, primary anastomosis is preferable to Hartmann's procedure as a treatment for perforated diverticulitis (Hinchey III or Hinchey IV disease). FUNDING Netherlands Organisation for Health Research and Development.
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19
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Beasant L, Brigden A, Parslow R, Apperley H, Keep T, Northam A, Wray C, King H, Langdon R, Mills N, Young B, Crawley E. Treatment preference and recruitment to pediatric RCTs: A systematic review. Contemp Clin Trials Commun 2019; 14:100335. [PMID: 30949611 PMCID: PMC6430075 DOI: 10.1016/j.conctc.2019.100335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 01/25/2019] [Accepted: 02/13/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Recruitment to pediatric randomised controlled trials (RCTs) can be a challenge, with ethical issues surrounding assent and consent. Pediatric RCTs frequently recruit from a smaller pool of patients making adequate recruitment difficult. One factor which influences recruitment and retention in pediatric trials is patient and parent preferences for treatment. PURPOSE To systematically review pediatric RCTs reporting treatment preference. METHODS Database searches included: MEDLINE, CINAHL, EMBASE, and COCHRANE.Qualitative or quantitative papers were eligible if they reported: pediatric population, (0-17 years) recruited to an RCT and reported treatment preference for all or some of the participants/parents in any clinical area. Data extraction included: Number of eligible participants consenting to randomisation arms, number of eligible patients not randomised because of treatment preference, and any further information reported on preferences (e.g., if parent preference was different from child). RESULTS Fifty-two studies were included. The number of eligible families declining participation in an RCT because of preference for treatment varied widely (between 2 and 70%) in feasibility, conventional and preference trial designs. Some families consented to trial involvement despite having preferences for a specific treatment. Data relating to 'participant flow and recruitment' was not always reported consistently, therefore numbers who were lost to follow-up or withdrew due to preference could not be extracted. CONCLUSIONS Families often have treatment preferences which may affect trial recruitment. Whilst children appear to hold treatment preferences, this is rarely reported. Further investigation is needed to understand the reasons for preference and the impact preference has on RCT recruitment, retention and outcome.
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Affiliation(s)
- L. Beasant
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, UK
| | - A. Brigden
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, UK
| | - R.M. Parslow
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, UK
| | - H. Apperley
- Department of Academic Paediatrics, Royal Alexandra Children's Hospital, Brighton and Sussex University Hospitals, UK
| | - T. Keep
- NHS Greater Glasgow and Clyde, UK
| | - A. Northam
- Department of Primary Care and Public Health, Royal Sussex County Hospital, Brighton and Sussex Medical School, UK
| | - C. Wray
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - H. King
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Trust, UK
| | - R. Langdon
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - N. Mills
- Population Health Sciences, Bristol Medical School, University of Bristol, UK
| | - B. Young
- Institute of Psychology, Health and Society, University of Liverpool, UK
| | - E. Crawley
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, UK
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20
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Turnbull AE, Sahetya SK, Biddison ELD, Hartog CS, Rubenfeld GD, Benoit DD, Guidet B, Gerritsen RT, Tonelli MR, Curtis JR. Competing and conflicting interests in the care of critically ill patients. Intensive Care Med 2018; 44:1628-1637. [PMID: 30046872 DOI: 10.1007/s00134-018-5326-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 07/16/2018] [Indexed: 12/26/2022]
Abstract
Medical professionals are expected to prioritize patient interests, and most patients trust physicians to act in their best interest. However, a single patient is never a physician's sole concern. The competing interests of other patients, clinicians, family members, hospital administrators, regulators, insurers, and trainees are omnipresent. While prioritizing patient interests is always a struggle, it is especially challenging and important in the ICU setting where most patients lack the ability to advocate for themselves or seek alternative sources of care. This review explores factors that increase the risk, or the perception, that an ICU physician will reason, recommend, or act in a way that is not in their patient's best interest and discusses steps that could help minimize the impact of these factors on patient care.
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Affiliation(s)
- Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument St, 5th Floor, Baltimore, MD, 21205, USA. .,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA. .,Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University, Baltimore, MD, USA.
| | - Sarina K Sahetya
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument St, 5th Floor, Baltimore, MD, 21205, USA
| | - E Lee Daugherty Biddison
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, 1830 E. Monument St, 5th Floor, Baltimore, MD, 21205, USA
| | - Christiane S Hartog
- Department for Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany.,Department of Anaesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Kreischa, Germany.,Patient- and Family-Centered Care, Klinik Bavaria, Kreischa, Germany
| | - Gordon D Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Bertrand Guidet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France.,Sorbonne Universités, Université Pierre et Marie Curie, Paris, France.,Institut National de la Santé et de la Recherche Médicale (INSERM), UMR S 1136, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France
| | - Rik T Gerritsen
- Department of Intensive Care, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - Mark R Tonelli
- Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA, USA.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
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21
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Morley RL, Edmondson MJ, Rowlands C, Blazeby JM, Hinchliffe RJ. Registration and publication of emergency and elective randomised controlled trials in surgery: a cohort study from trial registries. BMJ Open 2018; 8:e021700. [PMID: 29982216 PMCID: PMC6042627 DOI: 10.1136/bmjopen-2018-021700] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Emergency surgical practice constitutes 50% of the workload for surgeons, but there is a lack of high quality randomised controlled trials (RCTs) in emergency surgery. This study aims to establish the differences between the registration, completion and publication of emergency and elective surgical trials. DESIGN The clinicaltrials.gov and ISRCTN.com trials registry databases were searched for RCTs between 12 July 2010 and 12 July 2012 using the keyword 'surgery'. Publications were systematically searched for in Pubmed, MEDLINE and EMBASE. PARTICIPANTS Results with no surgical interventions were excluded. The remaining results were manually categorised into 'emergency' or 'elective' and 'surgical' or 'adjunct' by two reviewers. PRIMARY OUTCOME MEASURES Number of RCTs registered in emergency versus elective surgery. SECONDARY OUTCOME MEASURES Number of RCTs published in emergency versus elective surgery; reasons why trials remain unpublished; funding, sponsorship and impact of published articles; number of adjunct trials registered in emergency and elective surgery. RESULTS 2700 randomised trials were registered. 1173 trials were on a surgical population and of these, 414 trials were studying surgery. Only 9.4% (39/414) of surgical trials were in emergency surgery. The proportion of trials successfully published did not significantly differ between emergency and elective surgery (0.46 vs 0.52; mean difference (MD) -0.06, 95% CI -0.24 to 0.12). Unpublished emergency surgical trials were statistically equally likely to be terminated early compared with elective trials (0.33 vs 0.16; MD -0.18, 95% CI -0.06 to 0.41). Low accrual accounted for a similar majority in both groups (0.43 vs 0.46; MD -0.04, 95% CI -0.48 to 0.41). Unpublished trials in both groups were statistically equally likely to still be planning publication (0.52 vs 0.71; MD -0.18, 95% CI -0.43 to 0.07). CONCLUSION Fewer RCTs are registered in emergency than elective surgery. Once trials are registered both groups are equally likely to be published.
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Affiliation(s)
- Rachael L Morley
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- North Bristol NHS Trust, Bristol, UK
| | - Matthew J Edmondson
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Royal Infirmary, Bristol, UK
| | - Ceri Rowlands
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane M Blazeby
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Royal Infirmary, Bristol, UK
| | - Robert J Hinchliffe
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
- North Bristol NHS Trust, Bristol, UK
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22
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Randomized controlled trials in pediatric patients had higher completion rates than adult trials: a cross-sectional study. J Clin Epidemiol 2018; 100:53-60. [PMID: 29705092 DOI: 10.1016/j.jclinepi.2018.04.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 04/09/2018] [Accepted: 04/20/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Conduct of clinical trials is perceived to be more challenging in children than in adults. This study aimed to evaluate the impact of the age of participants on completion rates of randomized controlled trials (RCTs). STUDY DESIGN AND SETTING A cross-sectional study on RCTs registered in the ClinicalTrials.gov database. All RCTs registered up to December 31, 2016, were extracted and were classified according to their recruitment status: active, completed, or discontinued and according to the age of participants: children (<17 years), adults (≥18 years), and mixed-age population. A logistic regression model was applied to assess the impact of participant's age category on trial completion while controlling for other relevant trial features. RESULTS A total of 65,095 registered RCTs were identified. Among pediatric trials, 49.9% were completed and 8.5% were discontinued. Among adult and mixed age RCTs, respectively, 49.7% and 47.9% were completed whereas, 10.2% and 9.4% were discontinued. Overall, pediatric and mixed age RCTs were more likely to be registered as completed than adult RCTs (odds ratio: 1.16, 95% CI: 1.02-1.30; odds ratio: 1.15, 95% CI: 1.04-1.27, respectively). Also, funding source, type of intervention under evaluation, primary trial purpose, use of a blinding procedure, use of a placebo, and participants' assignment model were identified as independent predictors of RCT completion. CONCLUSION Contrary to current perceptions and despite several specific challenges, recruitment of children and adolescents is not a limiting factor to completing a RCT. Other study features such as funding source, impact completeness and should be carefully considered before initiating research.
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Rowlands C, Rooshenas L, Fairhurst K, Rees J, Gamble C, Blazeby JM. Detailed systematic analysis of recruitment strategies in randomised controlled trials in patients with an unscheduled admission to hospital. BMJ Open 2018; 8:e018581. [PMID: 29420230 PMCID: PMC5829602 DOI: 10.1136/bmjopen-2017-018581] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To examine the design and findings of recruitment studies in randomised controlled trials (RCTs) involving patients with an unscheduled hospital admission (UHA), to consider how to optimise recruitment in future RCTs of this nature. DESIGN Studies within the ORRCA database (Online Resource for Recruitment Research in Clinical TriAls; www.orrca.org.uk) that reported on recruitment to RCTs involving UHAs in patients >18 years were included. Extracted data included trial clinical details, and the rationale and main findings of the recruitment study. RESULTS Of 3114 articles populating ORRCA, 39 recruitment studies were eligible, focusing on 68 real and 13 hypothetical host RCTs. Four studies were prospectively planned investigations of recruitment interventions, one of which was a nested RCT. Most recruitment papers were reports of recruitment experiences from one or more 'real' RCTs (n=24) or studies using hypothetical RCTs (n=11). Rationales for conducting recruitment studies included limited time for informed consent (IC) and patients being too unwell to provide IC. Methods to optimise recruitment included providing patients with trial information in the prehospital setting, technology to allow recruiters to cover multiple sites, screening logs to uncover recruitment barriers, and verbal rather than written information and consent. CONCLUSION There is a paucity of high-quality research into recruitment in RCTs involving UHAs with only one nested randomised study evaluating a recruitment intervention. Among the remaining studies, methods to optimise recruitment focused on how to improve information provision in the prehospital setting and use of screening logs. Future research in this setting should focus on the prospective evaluation of the well-developed interventions to optimise recruitment.
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Affiliation(s)
- Ceri Rowlands
- MRC ConDuCT-II Hub for Trials Methodology Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- MRC ConDuCT-II Hub for Trials Methodology Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- School of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | - Katherine Fairhurst
- MRC ConDuCT-II Hub for Trials Methodology Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- School of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | - Jonathan Rees
- School of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Carrol Gamble
- MRC North West Hub for Trials Methodology Research, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Jane M Blazeby
- MRC ConDuCT-II Hub for Trials Methodology Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- School of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Wacher NH, Reyes-Sánchez M, Vargas-Sánchez HR, Gamiochipi-Cano M, Rascón-Pacheco RA, Gómez-Díaz RA, Doubova SV, Valladares-Salgado A, Sánchez-Becerra MC, Méndez-Padrón A, Valdez-González LA, Mondragón-González R, Cruz M, Salinas-Martinez AM, Garza-Sagástegui MG, Hernández-Rubí J, González-Hermosillo A, Borja-Aburto VH. Stepwise strategies to successfully recruit diabetes patients in a large research study in Mexican population. Prim Care Diabetes 2017; 11:297-304. [PMID: 28343902 DOI: 10.1016/j.pcd.2017.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 02/24/2017] [Accepted: 02/26/2017] [Indexed: 11/24/2022]
Abstract
AIMS Describe stepwise strategies (electronic chart review, patient preselection, call-center, personnel dedicated to recruitment) for the successful recruitment of >5000 type 2 diabetes patients in four months. METHODS Twenty-five family medicine clinics from Mexico City and the State of Mexico participated: 13 usual care, 6 specialized diabetes care and 6 chronic disease care. Appointments were scheduled from 11/3/2015 to 3/31/2016. Phone calls were generated automatically from an electronic database. A telephone questionnaire verified inclusion criteria, and scheduled an appointment, with a daily report of appointments, patient attendance, acceptance rate, and questionnaire completeness. Another recruitment log reviewed samples collected. Absolute number (percentage) of patients are reported. Means and standard deviations were estimated for continuous variables, χ2 test and independent "t" tests were used. OR and 95% CI were estimated. RESULTS 14,358 appointments were scheduled, 9146 (63.7%) attended their appointment: 5710 (62.4%) fulfilled inclusion criteria and 5244 agreed to participate (91.8% acceptance). Those accepting participation were more likely women, younger and with longer disease duration (p<0.05). The cost of the call-center service was $3,010,000.00 Mexican pesos (∼$31.70 USD per recruited patient). CONCLUSIONS Stepwise strategies recruit a high number of patients in a short time. Call centers offer a low cost per patient.
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Affiliation(s)
- Niels H Wacher
- Unidad de Investigación en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico.
| | - Mario Reyes-Sánchez
- División de Medicina Familiar, Unidad de Atención Primaria, IMSS, Mexico City, Mexico
| | | | - Mireya Gamiochipi-Cano
- Unidad de Investigación en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | | | - Rita A Gómez-Díaz
- Unidad de Investigación en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | - Svetlana V Doubova
- Unidad de Investigación en Epidemiología y Servicios de Salud, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | - Adán Valladares-Salgado
- Unidad de Investigación Médica en Bioquímica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | - Martha Catalina Sánchez-Becerra
- Unidad de Investigación Médica en Bioquímica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | - Araceli Méndez-Padrón
- Unidad de Investigación Médica en Bioquímica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | - Leticia A Valdez-González
- Unidad de Investigación en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | - Rafael Mondragón-González
- Unidad de Investigación en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | - Miguel Cruz
- Unidad de Investigación Médica en Bioquímica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | | | | | - Jaime Hernández-Rubí
- Departamento de Ingeniería en Sistemas Computacionales y Automatización, Instituto de Investigaciones en Matemáticas Aplicadas y en Sistemas, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Arturo González-Hermosillo
- Departamento de Ingeniería en Sistemas Computacionales y Automatización, Instituto de Investigaciones en Matemáticas Aplicadas y en Sistemas, Universidad Nacional Autónoma de México, Mexico City, Mexico
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Patient Eligibility for Randomized Controlled Trials in Critical Care Medicine: An International Two-Center Observational Study. Crit Care Med 2017; 45:216-224. [PMID: 27779514 DOI: 10.1097/ccm.0000000000002061] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE We conducted this study to determine the generalizability of information gained from randomized controlled trials in critically ill patients by assessing the incidence of eligibility for each trial. DESIGN Prospective, observational cohort study. We identified the 15 most highly cited randomized controlled trials in critical care medicine published between 1998 and 2008. We examined the inclusion and exclusion criteria for each randomized controlled trial and then assessed the eligibility of each patient admitted to a study ICU for each randomized controlled trial and calculated rates of potential trial eligibility in the cohort. SETTING Three ICUs in two academic medical centers in Canada and the United States. PATIENTS Adults admitted to participating medical or surgical ICU in November 2010 or July 2011. MEASUREMENTS AND MAIN RESULTS Among the 15 trials, the most common trial inclusion criteria were clinical criteria for sepsis (six trials) or acute respiratory distress syndrome (four trials), use of invasive mechanical ventilation (five trials) or related to ICU type or duration of ICU stay (five trials). Of the 93 patients admitted to a study ICU, 52% of patients (n = 48) did not meet enrollment criteria for any studied randomized controlled trial and 30% (n = 28) were eligible for only one of the 15. Trial ineligibility was mostly due to failure to meet inclusion criteria (87% of screening assessments) rather than meeting specific exclusion criteria (52% of screening assessments). Of the positive screening assessments, 85% occurred on the first day of ICU admission. CONCLUSIONS Slightly more than half of the patients assessed were not eligible for enrollment in any of 15 major randomized controlled trials in critical care, most often due to the absence of the specific clinical condition of study. The majority of patients who met criteria for a randomized controlled trial did so on the first day of ICU admission.
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Schandelmaier S, Tomonaga Y, Bassler D, Meerpohl JJ, von Elm E, You JJ, Bluemle A, Lamontagne F, Saccilotto R, Amstutz A, Bengough T, Stegert M, Olu KK, Tikkinen KAO, Neumann I, Carrasco-Labra A, Faulhaber M, Mulla SM, Mertz D, Akl EA, Sun X, Busse JW, Ferreira-González I, Nordmann A, Gloy V, Raatz H, Moja L, Rosenthal R, Ebrahim S, Vandvik PO, Johnston BC, Walter MA, Burnand B, Schwenkglenks M, Hemkens LG, Guyatt G, Bucher HC, Kasenda B, Briel M. Premature Discontinuation of Pediatric Randomized Controlled Trials: A Retrospective Cohort Study. J Pediatr 2017; 184:209-214.e1. [PMID: 28410086 DOI: 10.1016/j.jpeds.2017.01.071] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 12/30/2016] [Accepted: 01/30/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To determine the proportion of pediatric randomized controlled trials (RCTs) that are prematurely discontinued, examine the reasons for discontinuation, and compare the risk for recruitment failure in pediatric and adult RCTs. STUDY DESIGN A retrospective cohort study of RCTs approved by 1 of 6 Research Ethics Committees (RECs) in Switzerland, Germany, and Canada between 2000 and 2003. We recorded trial characteristics, trial discontinuation, and reasons for discontinuation from protocols, corresponding publications, REC files, and a survey of trialists. RESULTS We included 894 RCTs, of which 86 enrolled children and 808 enrolled adults. Forty percent of the pediatric RCTs and 29% of the adult RCTs were discontinued. Slow recruitment accounted for 56% of pediatric RCT discontinuations and 43% of adult RCT discontinuations. Multivariable logistic regression analyses suggested that pediatric RCT was not an independent risk factor for recruitment failure after adjustment for other potential risk factors (aOR, 1.22; 95% CI, 0.57-2.63). Independent risk factors were acute care setting (aOR, 4.00; 95% CI, 1.72-9.31), nonindustry sponsorship (aOR, 4.45; 95% CI, 2.59-7.65), and smaller planned sample size (aOR, 1.05; 95% CI 1.01-1.09, in decrements of 100 participants). CONCLUSION Forty percent of pediatric RCTs were discontinued prematurely, owing predominately to slow recruitment. Enrollment of children was not an independent risk factor for recruitment failure.
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Affiliation(s)
- Stefan Schandelmaier
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Academy of Swiss Insurance Medicine, University Hospital Basel, Basel, Switzerland.
| | - Yuki Tomonaga
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Joerg J Meerpohl
- German Cochrane Centre, Medical Center, University of Freiburg, Freiburg, Germany; Center of Research in Epidemiology and Statistics Sorbonne Paris Cité-U1153, INSERM/Université Paris Descartes, Cochrane France, Hôpital Hôtel-Dieu, Paris Cedex 04, France
| | - Erik von Elm
- Cochrane Switzerland, Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - John J You
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anette Bluemle
- German Cochrane Centre, Medical Center, University of Freiburg, Freiburg, Germany
| | - Francois Lamontagne
- Centre de Recherche Clinique du Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Ramon Saccilotto
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Alain Amstutz
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Theresa Bengough
- Department of Health and Society, Austrian Federal Institute for Health Care, Vienna, Austria
| | - Mihaela Stegert
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Kelechi K Olu
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Kari A O Tikkinen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Departments of Urology and Public Health, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ignacio Neumann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Alonso Carrasco-Labra
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Evidence-Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago, Chile
| | - Markus Faulhaber
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Sohail M Mulla
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Dominik Mertz
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote Institute for Infectious Diseases Research, McMaster University, Hamilton, ON, Canada
| | - Elie A Akl
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Xin Sun
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jason W Busse
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - Ignacio Ferreira-González
- Epidemiology Unit, Department of Cardiology, Vall d'Hebron Hospital and CIBER de Epidemiología y Salud Publica (CIBERESP), Barcelona, Spain
| | - Alain Nordmann
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Viktoria Gloy
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Institute of Nuclear Medicine, University Hospital Bern, Bern, Switzerland
| | - Heike Raatz
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Lorenzo Moja
- IRCCS Orthopedic Institute Galeazzi, Milano, Italy
| | - Rachel Rosenthal
- Department of Surgery, University Hospital Basel, Basel, Switzerland
| | - Shanil Ebrahim
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada; Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Stanford Prevention Research Center, Stanford University, Stanford, CA
| | - Per O Vandvik
- Department of Medicine, Innlandet Hospital Trust-Division Gjøvik, Oppland, Norway
| | - Bradley C Johnston
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Martin A Walter
- Institute of Nuclear Medicine, University Hospital Bern, Bern, Switzerland
| | - Bernard Burnand
- Cochrane Switzerland, Institute of Social and Preventive Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Matthias Schwenkglenks
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Lars G Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Benjamin Kasenda
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Department of Haematology/Oncology and Palliative Care, Klinikum Stuttgart, Stuttgart, Germany
| | - Matthias Briel
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Clinical Research, University of Basel, Basel, Switzerland
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Stange R, Schneider B, Albrecht U, Mueller V, Schnitker J, Michalsen A. Results of a randomized, prospective, double-dummy, double-blind trial to compare efficacy and safety of a herbal combination containing Tropaeoli majoris herba and Armoraciae rusticanae radix with co-trimoxazole in patients with acute and uncomplicated cystitis. Res Rep Urol 2017; 9:43-50. [PMID: 28352615 PMCID: PMC5359132 DOI: 10.2147/rru.s121203] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objectives To demonstrate non-inferiority of an herbal combination (horseradish root and nasturtium herb) to an antibiotic (co-trimoxazole) in acute uncomplicated cystitis. Design Randomized, prospective, double-blind, double-dummy, multicenter, phase III clinical study, using block randomization of 4 blocks (size 2). Setting Twenty-six centers in Germany, from May 2011 to June 2013. Participants Adult patients (median age, 38.5 years; 90% female) with acute uncomplicated cystitis confirmed via urinalysis and bacterial counts. Interventions Patients received the herbal combination (five tablets, four times per day) or the antibiotic (two tablets daily) for a period of 7 or 3 days, respectively, followed by a 21-days without drug treatment. Placebos ensured blinding. Primary and secondary outcome measures The primary endpoint was the percentage of responders, expressed as reduction of germ count from >105 to <103 CFU/mL of pathogens between visit 1 (day 0) and 3 (day 15). Secondary endpoints included change of symptom scores, duration of symptoms, efficacy assessments, relapse frequency, and safety. A sample size of 178 patients per group was estimated. Results Of the 96 randomized patients (intent-to-treat; 45 in the phytotherapy group, 51 in the antibiotic group), 51 were considered per-protocol patients (22 in the phytotherapy group, 29 in the antibiotic group). Responder rates were 10/22 (45.5%) for the phytotherapy group and 15/29 (51.1%) for the antibiotic group (group difference: −6.27% [95% CI: −33.90%–21.3%]). The study was terminated prematurely due to slow recruitment rates. Non-inferiority could not be assumed by predefined criteria. During the follow-up period, one relapse occurred in each group. Both treatments were well tolerated. Conclusion This clinical trial indicates comparable efficacy of the herbal combination and antibiotic, although non-inferiority was not proved. However, the results and lessons learned are important for the planning of future trials. Issues that led to the premature trial discontinuation were considered.
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Affiliation(s)
- Rainer Stange
- Internal and Complementary Medicine, Immanuel Krankenhaus Berlin-Wannsee, Berlin
| | | | | | | | | | - Andreas Michalsen
- Internal and Complementary Medicine, Immanuel Krankenhaus Berlin-Wannsee, Berlin
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von Niederhäusern B, Orleth A, Schädelin S, Rawi N, Velkopolszky M, Becherer C, Benkert P, Satalkar P, Briel M, Pauli-Magnus C. Generating evidence on a risk-based monitoring approach in the academic setting - lessons learned. BMC Med Res Methodol 2017; 17:26. [PMID: 28193170 PMCID: PMC5307807 DOI: 10.1186/s12874-017-0308-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 02/04/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In spite of efforts to employ risk-based strategies to increase monitoring efficiency in the academic setting, empirical evidence on their effectiveness remains sparse. This mixed-methods study aimed to evaluate the risk-based on-site monitoring approach currently followed at our academic institution. METHODS We selected all studies monitored by the Clinical Trial Unit (CTU) according to Risk ADApted MONitoring (ADAMON) at the University Hospital Basel, Switzerland, between 01.01.2012 and 31.12.2014. We extracted study characteristics and monitoring information from the CTU Enterprise Resource Management system and from monitoring reports of all selected studies. We summarized the data descriptively. Additionally, we conducted semi-structured interviews with the three current CTU monitors. RESULTS During the observation period, a total of 214 monitoring visits were conducted in 43 studies resulting in 2961 documented monitoring findings. Our risk-based approach predominantly identified administrative (46.2%) and patient right findings (49.1%). We identified observational study design, high ADAMON risk category, industry sponsorship, the presence of an electronic database, experienced site staff, and inclusion of vulnerable study population to be factors associated with lower numbers of findings. The monitors understand the positive aspects of a risk-based approach but fear missing systematic errors due to the low frequency of visits. CONCLUSIONS We show that the factors mostly increasing the risk for on-site monitoring findings are underrepresented in the current risk analysis scheme. Our risk-based on-site approach should further be complemented by centralized data checks, allowing monitors to transform their role towards partners for overall trial quality, and success.
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Affiliation(s)
- Belinda von Niederhäusern
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel, Basel, Switzerland.
| | - Annette Orleth
- Department of Medicine, Biomedicine and Clinical Research, Neurology, University Hospital Basel, Basel, Switzerland
| | - Sabine Schädelin
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | | | - Martin Velkopolszky
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Claudia Becherer
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Pascal Benkert
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Priya Satalkar
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Matthias Briel
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, Basel, Switzerland.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Christiane Pauli-Magnus
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel, Basel, Switzerland
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