The current use of feasibility studies in the assessment of feasibility for stepped-wedge cluster randomised trials: a systematic review

A systematic review of stepped wedge cluster randomized trials in high impact journals: assessing the design, rationale, and analysis

OBJECTIVES

Stepped wedge cluster randomized trials (SW-CRTs) are an appealing study design because they enable sequential roll out of an intervention across clusters, bringing logistical advantages. This review aimed to evaluate the design rationale, design features, stepped wedge diagram, and analytical approaches of SW-CRTs published in high-impact medical journals from 2020 to 2023, focusing particularly on adherence to key guidelines from the Consolidated Standards of Reporting Trials extension to SW-CRTs.

STUDY DESIGN AND SETTING

We conducted searches across PubMed and Cochrane Central Registry of Controlled Trials databases for SW-CRTs published between January 2020 and December 2023 in eight high-impact journals. Eligibility criteria included peer-reviewed publications of randomized SW-CRTs involving human participants, published in English.

RESULTS

Of the 23 SW-CRTs included in the review, 70% had "stepped wedge" explicitly mentioned in their titles. Most studies (96%) included a stepped wedge diagram, but only 65% of these diagrams clearly communicated the duration of each time period. There was considerable variability in design features, including number of sequences (median of 7, range 3-20) and clusters (median of 15, range 9-19). The majority of trials (78%) provided robust justifications for selecting a SW-CRT design, for example, citing practical or logistical constraints. However, 22% of the studies offered less convincing rationales. Generalized linear mixed models were the most frequent analysis method employed.

CONCLUSION

Our review has highlighted areas for improvement in the presentation of SW-CRTs, particularly in clearly indicating the duration of time periods within diagrams and providing robust justifications for selecting a SW-CRT design.

PLAIN LANGUAGE SUMMARY

The stepped wedge cluster randomized trial (SW-CRT) is a type of study design that introduces interventions to different groups at different times. This review examined reports of SW-CRTs published in top medical journals from 2020 to 2023 to see if they followed certain guidelines such as including the word "stepped wedge" in their title. A total of 23 SW-CRTs were included in the review, with 70% mentioning "stepped wedge" in the title. Most (96%) included diagrams, but only 65% showed the duration of each time period clearly. There was variability in design, such as variations in the number of sequences and groups. 78% gave valid reasons for using SW-CRTs, citing practical benefits, whereas 22% did not give convincing reasons. This review suggests that improvements can be made in the presentation of stepped wedge diagrams and in the reporting of SW-CRTs. Researchers should clearly report the length of time periods and provide strong justifications for their design choice.

Assessing the implementation and effectiveness of early integrated palliative care in long-term care facilities in France: an interventional mixed-methods study protocol

BACKGROUND

Majority of residents in long-term care facilities (LTCF) have limited and delayed access to palliative care even though many suffer from incurable chronic illnesses that will likely require the provision of palliative care. We present the study protocol of "PADI-Palli", an intervention aims to advance early integrated palliative care into standard care delivered in LTCF. This study will assess the effectiveness of early integrated palliative care on palliative care accessibility for older persons in LTCF, and identify the key factors for the successful implementation of early integrated palliative care and its sustainability in the LTCF context.

METHODS

This multicentre interventional study utilises a pragmatic research design with a convergent parallel mixed-methods approach. The qualitative study will use a case study design and the quantitative study will use a stepped wedge cluster randomised trial. In total, 21 participating LTCF from three French regions will be randomly allocated to one of seven clusters. The clusters will cross over from the usual care to the active intervention condition over the course of the study. The primary outcome relates to the accurate identification of palliative care needs and early access to palliative care for LTCF residents. Secondary outcomes are quality of care, quality of life for residents and their families, and quality of life at work for professionals. Measurements will be performed before and after the intervention. Implementation and evaluation of PADI-Palli intervention is grounded in the Consolidated Framework for Implementation Research.

DISCUSSION

Existing evidence demonstrates that early integrated palliative care in cancer care leads to a significant improvement in patient outcomes and processes of care. Little is known, however, about early integrated palliative care in the context of LTCF for older persons. This study has the potential to fill this gap in the literature by providing evidence on the effectiveness of early integrated palliative care for older persons in LTCF. Moreover, this study will provide a better understanding of the relevant contextual elements that facilitate or hinder early integrated palliative care implementation and transferability. If proven effective, this intervention can be scaled to other care settings in which older persons require palliative care.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04708002; National registration: ID-RCB number: 2020-A01832-37.

Systematic review of the characteristics of school-based feasibility cluster randomised trials of interventions for improving the health of pupils in the UK

Background

The last 20 years have seen a marked increase in the use of cluster randomised trials (CRTs) in schools to evaluate interventions for improving pupil health outcomes. Schools have limited resources and participating in full-scale trials can be challenging and costly, given their main purpose is education. Feasibility studies can be used to identify challenges with implementing interventions and delivering trials. This systematic review summarises methodological characteristics and objectives of school-based cluster randomised feasibility studies in the United Kingdom (UK).

Methods

We systematically searched MEDLINE from inception to 31 December 2020. Eligible papers were school-based feasibility CRTs that included health outcomes measured on pupils.

Results

Of 3285 articles identified, 24 were included. School-based feasibility CRTs have been increasingly used in the UK since the first publication in 2008. Five (21%) studies provided justification for the use of the CRT design. Three (13%) studies provided details of a formal sample size calculation, with only one of these allowing for clustering. The median (IQR; range) recruited sample size was 7.5 (4.5 to 9; 2 to 37) schools and 274 (179 to 557; 29 to 1567) pupils. The most common feasibility objectives were to estimate the potential effectiveness of the intervention (n = 17; 71%), assess acceptability of the intervention (n = 16; 67%), and estimate the recruitment/retention rates (n = 15; 63%). Only one study was used to assess whether cluster randomisation was appropriate, and none of the studies that randomised clusters before recruiting pupils assessed the possibility of recruitment bias. Besides potential effectiveness, cost-effectiveness, and the intra-cluster correlation coefficient, no studies quantified the precision of the feasibility parameter estimates.

Conclusions

Feasibility CRTs are increasingly used in schools prior to definitive trials of interventions for improving health in pupils. The average sample size of studies included in this review would be large enough to estimate pupil-level feasibility parameters (e.g., percentage followed up) with reasonable precision. The review highlights the need for clearer sample size justification and better reporting of the precision with which feasibility parameters are estimated. Better use could be made of feasibility CRTs to assess challenges that are specific to the cluster design.

Trial registration

PROSPERO: CRD42020218993.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01098-w.

Recruitment and implementation challenges were common in stepped-wedge cluster randomized trials: results from a methodological review

OBJECTIVE

To explore challenges in recruitment and intervention implementation in recent stepped-wedge cluster randomized trials (SW-CRTs).

STUDY DESIGN AND SETTING

We searched PubMed to identify primary reports of SW-CRTs (2019-2020). Two reviewers independently screened studies and extracted data from each report. Recruitment challenge was defined as planned number of clusters or participants not achieved, or any reported changes made to the design to address recruitment difficulties. Implementation challenge was defined as early, late or no implementation of the intervention in at least one cluster.

RESULTS

Of 55 SW-CRTs, 18 (33%) had a recruitment challenge, 23 (42%) had none, and for 14 (26%) it was impossible to judge. At least one implementation challenge was present in 24 (44%), 8 (15%) had none, and for 23 (42%) it was impossible to judge. Of the 35 (64%) trials with recruitment or implementation challenges, 18 (72%) had one or more modifications of their design, most often a modification of the trial duration.

CONCLUSION

Investigators must be aware of the risks of recruitment or implementation challenges when considering use of a SW-CRT design. Mitigating strategies should be adopted when planning the trial. More transparent reporting of planned and actual design features is required.

Are some feasibility studies more feasible than others? A review of the outcomes of feasibility studies on the ISRCTN registry

Background

Feasibility studies are often conducted before committing to a randomised controlled trial (RCT), yet there is little published evidence to inform how useful feasibility studies are, especially in terms of adding or reducing waste in research. This study attempted to examine how many feasibility studies demonstrated that the full trial was feasible and whether some feasibility studies were inherently likely to be feasible or not feasible, based on the topic area and/or research setting.

Methods

Keyword searches were conducted on the International Standard Randomised Controlled Trials Number (ISRCTN) registry to identify all completed feasibility studies which had been conducted in the UK.

Results

A total of 625 records from the 1933 identified were reviewed before it became evident that it would be futile to continue. Of 329 feasibility studies identified, 160 had a known outcome (49%), 133 (83%) trials were deemed to be feasible and only 27 (17%) were reported to be non-feasible. There were therefore too few studies to allow the intended comparison of differences in non-feasible studies by topic and/or setting.

Conclusions

There were too few studies reported as non-feasible to draw any useful conclusions on whether topic and/or setting had an effect. However, the high feasibility rate (83%) may suggest that non-feasible studies are subject to publication bias or that many feasible studies are redundant and may be adding waste to the research pathway.

Implementation of a stepped wedge cluster randomized trial to evaluate a hospital mobility program

Background

Stepped wedge cluster randomized trials (SW-CRT) are increasingly used to evaluate new clinical programs, yet there is limited guidance on practical aspects of applying this design. We report our early experiences conducting a SW-CRT to examine an inpatient mobility program (STRIDE) in the Veterans Health Administration (VHA). We provide recommendations for future research using this design to evaluate clinical programs.

Methods

Based on data from study records and reflections from the investigator team, we describe and assess the design and initial stages of a SW-CRT, from site recruitment to program launch in 8 VHA hospitals.

Results

Site recruitment consisted of thirty 1-h conference calls with representatives from 22 individual VAs who expressed interest in implementing STRIDE. Of these, 8 hospitals were enrolled and randomly assigned in two stratified blocks (4 hospitals per block) to a STRIDE launch date. Block 1 randomization occurred in July 2017 with first STRIDE launch in December 2017; block 2 randomization occurred in April 2018 with first STRIDE launch in January 2019. The primary study outcome of discharge destination will be assessed using routinely collected data in the electronic health record (EHR). Within randomized blocks, two hospitals per sequence launched STRIDE approximately every 3 months with primary outcome assessment paused during the 3-month time period of program launch. All sites received 6–8 implementation support calls, according to a pre-specified schedule, from the time of recruitment to program launch, and all 8 sites successfully launched within their assigned 3-month window. Seven of the eight sites initially started with a limited roll out (for example on one ward) or modified version of STRIDE (for example, using existing staff to conduct walks until new positions were filled).

Conclusions

Future studies should incorporate sufficient time for site recruitment and carefully consider the following to inform design of SW-CRTs to evaluate rollout of a new clinical program: (1) whether a blocked randomization fits study needs, (2) the amount of time and implementation support sites will need to start their programs, and (3) whether clinical programs are likely to include a “ramp-up” period. Successful execution of SW-CRT designs requires both adherence to rigorous design principles and also careful consideration of logistical requirements for timing of program roll out.

Trial registration

ClinicalsTrials.gov NCT03300336. Prospectively registered on 3 October 2017.

Design, rationale and analysis plan for the Stand Up for Health trial in contact centres: a stepped wedge feasibility study

Background

Contact centres are one of the most sedentary workplaces, with employees spending a very high proportion of their working day sitting down. About a quarter of contact centre staff regularly experience musculoskeletal health problems due to high levels of sedentary behaviour, including lower back pain. There have been no previous randomised studies specifically aiming to reduce sedentary behaviour in contact centre staff. To address this gap, the Stand Up for Health (SUH) study aims to test the feasibility and acceptability of a complex theory-based intervention to reduce sedentary behaviour in contact centres.

Methods

The Stand Up for Health study has a stepped wedge cluster randomised trial design, which is a pragmatic design whereby clusters (contact centres) are randomised to time points at which they will begin to receive the intervention. All contact centre staff have the opportunity to experience the intervention. To minimise the resource burden in this feasibility study, data collection is not continuous, but undertaken on a selective number of occasions, so the stepped wedge design is “incomplete”. Eleven contact centres in England and Scotland have been recruited, and the sample size is approximately 27 per centre (270 in total). The statistical analysis will predominantly focus on assessing feasibility, including the calculation of recruitment rates and rates of attrition. Exploratory analysis will be performed to compare objectively measured sedentary time in the workplace (measured using an activPAL™ device) between intervention and control conditions using a linear mixed effects regression model.

Discussion

To our knowledge, this is the first stepped wedge feasibility study conducted in call centres. The rationale and justification of our novel staircase stepped wedge design has been presented, and we hope that by presenting our study design and statistical analysis plan, it will contribute to the literature on stepped wedge trials, and in particular feasibility stepped wedge trials. The findings of the study will also help inform whether this is a suitable design for other settings where data collection is challenging.

Trial registration

The trial has been registered on the ISRCTN database: http://www.isrctn.com/ISRCTN11580369

A non-randomized pilot study to test the feasibility of treating chronic pain and opioid prescription use in rural areas with acceptance and commitment therapy (T-PACT)

Chronic non-cancer pain (CNCP) involves one-third of the US population, and prescription opioids contribute to the opioid epidemic. The Centers for Disease Control and Prevention emphasizes maximizing non-opioid treatment, but many rural populations cannot access alternative therapies. Clinical and Translational Science Award hubs across four rural states performed a multi-site, single-arm intervention feasibility study testing methods and procedures of implementing a behavioral intervention, acceptance and commitment therapy, in primary care CNCP patients on chronic opioids. Using the CONSORT extension for feasibility studies, we describe lessons learned in recruiting/retaining participants, intervention implementation, data measurement, and multi-site procedures. Results inform a future definitive trial and potentially others conducting rural trials.

A website for pilot and feasibility studies: giving your research the best chance of success

This editorial introduces a website for pilot and feasibility studies. Pilot and feasibility studies are about giving research the best chance of success, but must be performed well to have the greatest benefit. The website was developed by the Pilot and Feasibility Studies collaboration who developed the CONSORT Extension to Pilot and Feasibility Trials as a resource to help triallists and researchers perform well conducted pilot and feasibility studies. The website is also aimed at those interested in the latest methodology for these studies. We aim to keep the site updated with the latest publications and events related to pilot and feasibility studies and welcome feedback and suggestions from the research community on further resources or events to add.