1
|
Anusic N, Sessler DI. Innovative designs for trials informing the care of cardiac surgical patients: Part II. Curr Opin Anaesthesiol 2024; 37:49-54. [PMID: 38085856 DOI: 10.1097/aco.0000000000001334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
PURPOSE OF REVIEW This review examines advances in clinical trial methodologies relevant to cardiac anesthesia. It focuses on innovative approaches, including factorial randomization, composite outcomes, and cluster randomized trials, which enhance the efficiency, practical relevance, and generalizability of trial outcomes. RECENT FINDINGS Factorial randomization is becoming popular because the approach allows investigators to simultaneously evaluate two or more interventions. Furthermore, factorial designs can evaluate interactions among treatments which is highly relevant information that cannot be obtained from separate trials. Composite outcomes are also increasingly utilized, combining multiple individual outcomes into a single measure, which increases statistical power and can better represent relevant physiology. Designing valid composites requires careful consideration of component outcome severity and incidence. Cluster randomized trials, including stepped wedge and multiple crossover designs, address the challenges of group-level effects and shared environments. SUMMARY The evolution of clinical trial designs is marked by a shift towards methodologies that enhance efficiency and provide more nuanced insights into treatment effects. These include factorial designs for simultaneous intervention assessment, composite outcomes for comprehensive physiological representation, and cluster trials for group-level effect analysis. Such advancements are shaping the future of clinical research, making it more relevant, efficient, and broadly applicable.
Collapse
Affiliation(s)
- Nikola Anusic
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | | |
Collapse
|
2
|
Salmasi V, Terkawi AS, Mackey SC. Pragmatic Comparative Effectiveness Trials and Learning Health Systems in Pain Medicine: Opportunities and Challenges. Anesthesiol Clin 2023; 41:503-517. [PMID: 37245953 PMCID: PMC10926352 DOI: 10.1016/j.anclin.2023.03.010] [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] [Indexed: 05/30/2023]
Abstract
Large randomized clinical trials or aggregates of clinical trials represent the highest levels of clinical evidence because they minimize different sources of confounding and bias. The current review provides an in-depth discussion of the challenges faced and methods we can use to overcome these obstacles to tailor novel designs of pragmatic effectiveness trials to pain medicine. The authors describe their experiences with an open-source learning health system to collect high-quality evidence and conduct pragmatic clinical trials within a busy academic pain center.
Collapse
Affiliation(s)
- Vafi Salmasi
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, USA.
| | - Abdullah Sulieman Terkawi
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, USA
| |
Collapse
|
3
|
Routine Postsurgical Anesthesia Visit to Improve 30-day Morbidity and Mortality: A Multicenter, Stepped-wedge Cluster Randomized Interventional Study (The TRACE Study). Ann Surg 2023; 277:375-380. [PMID: 34029230 PMCID: PMC9891267 DOI: 10.1097/sla.0000000000004954] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To study the impact of a standardized postoperative anesthesia visit on 30-day mortality in medium to high-risk elective surgical patients. BACKGROUND Postoperative complications are the leading cause of perioperative morbidity and mortality. Although modified early warning scores (MEWS) were instituted to monitor vital functions and improve postoperative outcome, we hypothesized that complementary anesthesia expertise is needed to adequately identify early deterioration. METHODS In a prospective, multicenter, stepped-wedge cluster randomized interventional study in 9 academic and nonacademic hospitals in the Netherlands, we studied the impact of adding standardized postoperative anesthesia visits on day 1 and 3 to routine use of MEWS in 5473 patients undergoing elective noncardiac surgery. Primary outcome was 30-day mortality. Secondary outcomes included: incidence of postoperative complications, length of hospital stay, and intensive care unit admission. RESULTS Patients were enrolled between October 2016 and August 2018. Informed consent was obtained from 5473 patients of which 5190 were eligible for statistical analyses, 2490 in the control and 2700 in the intervention group. Thirty-day mortality was 0.56% (n = 14) in the control and 0.44% (n = 12) in the intervention group (odds ratio 0.74, 95% Confidence interval 0.34-1.62). Incidence of postoperative complications did not differ between groups except for renal complications which was higher in the control group (1.7% (n = 41) vs 1.0% (n = 27), P = 0.014). Median length of hospital stay did not differ significantly between groups. During the postanesthesia visits, for 16% (n = 437) and 11% (n = 293) of patients recommendations were given on day 1 and 3, respectively, of which 67% (n = 293) and 69% (n = 202) were followed up. CONCLUSIONS The combination of MEWS and a postoperative anesthesia visit did not reduce 30-day mortality. Whether a postoperative anesthesia visit with strong adherence to the recommendations provided and in a high-risk population might have a stronger impact on postoperative mortality remains to be determined. TRIAL REGISTRATION Netherlands Trial Registration, NTR5506/ NL5249, https://www.trialregister.nl/trial/5249.
Collapse
|
4
|
Stolze A, van de Garde EMW, Posthuma LM, Hollmann MW, de Korte-de Boer D, Smit-Fun VM, Buhre WFFA, Boer C, Noordzij PG. Validation of the PreOperative Score to predict Post-Operative Mortality (POSPOM) in Dutch non-cardiac surgery patients. BMC Anesthesiol 2022; 22:58. [PMID: 35240985 PMCID: PMC8892805 DOI: 10.1186/s12871-022-01564-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/21/2021] [Indexed: 11/13/2022] Open
Abstract
Background Standardized risk assessment tools can be used to identify patients at higher risk for postoperative complications and death. In this study, we validate the PreOperative Score to predict Post-Operative Mortality (POSPOM) for in-hospital mortality in a large cohort of non-cardiac surgery patients. In addition, the performance of POSPOM to predict postoperative complications was studied. Methods Data from the control cohort of the TRACE (routine posTsuRgical Anesthesia visit to improve patient outComE) study was analysed. POSPOM scores for each patient were calculated post-hoc. Observed in-hospital mortality was compared with predicted mortality according to POSPOM. Discrimination was assessed by receiver operating characteristic curves with C-statistics for in-hospital mortality and postoperative complications. To describe the performance of POSPOM sensitivity, specificity, negative predictive values, and positive predictive values were calculated. For in-hospital mortality, calibration was assessed by a calibration plot. Results In 2490 patients, the observed in-hospital mortality was 0.5%, compared to 1.3% as predicted by POSPOM. 27.1% of patients had at least one postoperative complication of which 22.4% had a major complication. For in-hospital mortality, POSPOM showed strong discrimination with a C-statistic of 0.86 (95% CI, 0.78–0.93). For the prediction of complications, the discrimination was poor to fair depending on the severity of the complication. The calibration plot showed poor calibration of POSPOM with an overestimation of in-hospital mortality. Conclusion Despite the strong discriminatory performance, POSPOM showed poor calibration with an overestimation of in-hospital mortality. Performance of POSPOM for the prediction of any postoperative complication was poor but improved according to severity.
Collapse
Affiliation(s)
- Annick Stolze
- Department of Anesthesiology, Amsterdam University Medical Centre, VU University Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| | - Ewoudt M W van de Garde
- Department of Clinical Pharmacy, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Linda M Posthuma
- Department of Anesthesiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Dianne de Korte-de Boer
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Valérie M Smit-Fun
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Wolfgang F F A Buhre
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Christa Boer
- Department of Anesthesiology, Amsterdam University Medical Centre, VU University Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Peter G Noordzij
- Department of Anesthesiology, Intensive Care and Pain management, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | | |
Collapse
|
5
|
Hollmann MW, de Korte-de Boer D, Boer C, Buhre WFFA. The Routine posTsuRgical Anesthesia visit to improve patient outComE (TRACE) study: lessons learned. Br J Anaesth 2021; 127:e140-e142. [PMID: 34426010 DOI: 10.1016/j.bja.2021.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/22/2021] [Accepted: 07/09/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Markus W Hollmann
- Department of Anesthesiology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Dianne de Korte-de Boer
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Christa Boer
- Department of Anesthesiology, Amsterdam University Medical Centre, VU University, Amsterdam, The Netherlands.
| | - Wolfgang F F A Buhre
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| |
Collapse
|
6
|
Ajmera Y, Singhal S, Dwivedi SN, Dey AB. The changing perspective of clinical trial designs. Perspect Clin Res 2021; 12:66-71. [PMID: 34012901 PMCID: PMC8112330 DOI: 10.4103/picr.picr_138_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/23/2020] [Accepted: 06/29/2020] [Indexed: 12/18/2022] Open
Abstract
Maintaining health and well-being of the population is a universal priority. Governments around the globe are therefore seeking greater efficiency and better outcomes from researches being held. Although large randomized trials or systematic review of several large trials provides the highest level of evidence, the intricate cost, time, and difficulties of conventional trials have led to questions about their sustainability commanding search for alternative approaches. Demands for improved competences in medical research have led to mounting interest in newer clinical trial designs. This article provides an insight into newer clinical trial designs, including cluster trials, adaptive designs, the master protocols along with their strengths, weaknesses, and which trials design should be opted for in different clinical scenarios.
Collapse
Affiliation(s)
- Yamini Ajmera
- Department of Geriatric Medicine, AIIMS, New Delhi, India
| | - Sunny Singhal
- Department of Geriatric Medicine, AIIMS, New Delhi, India
| | - S N Dwivedi
- Department of Biostatistics, AIIMS, New Delhi, India
| | - A B Dey
- Department of Geriatric Medicine, AIIMS, New Delhi, India
| |
Collapse
|
7
|
Lung T, Si L, Hooper R, Di Tanna GL. Health Economic Evaluation Alongside Stepped Wedge Trials: A Methodological Systematic Review. PHARMACOECONOMICS 2021; 39:63-80. [PMID: 33015754 DOI: 10.1007/s40273-020-00963-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/16/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Recently, there has been an increase in use of the stepped wedge trial (SWT) design in the context of health services research, due to its pragmatic and methodological advantages over the parallel group design. OBJECTIVE Our objective was to summarise the statistical methods used when conducting economic evaluations alongside SWTs. METHODS A systematic literature search extending to February 2020 was conducted in the PubMed, Scopus, Cochrane and National Health Service Economic Evaluation Database (NHS-EED) databases to find and evaluate studies where there was an intention to conduct an economic evaluation alongside an SWT. Studies were assessed for their eligibility, findings, reporting of statistical methods and quality of reporting. RESULTS Of the 586 studies retrieved from the literature search, 69 studies were identified and included in this systematic review. A total of 54 studies were published protocols, with eight economic evaluations and seven studies reporting full trial results. Included studies varied in terms of their reporting of statistical methods, in both detail and methodology. There were 34 studies that did not report any statistical methods for the economic evaluation, and only 16 studies reported appropriate methods, mainly using some form of mixed/multilevel model, and two used seemingly unrelated regression. Twelve studies reported the use of generic bootstrap methods and other modelling techniques, whilst the remaining studies failed to appropriately account for clustering, correlation or adjustment for time. CONCLUSIONS The use of appropriate statistical methods that account for time, clustering and correlation between costs and outcomes is an important part of SWT health economics analysis, one that will benefit from an effort to communicate the methods available and their performance.
Collapse
Affiliation(s)
- Thomas Lung
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, 2042, Australia
- Faculty of Medicine and Health, School of Public Health, Edward Ford Building A27, University of Sydney, Sydney, NSW, 2006, Australia
| | - Lei Si
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, 2042, Australia
- School of Health Policy & Management, Nanjing Medical University, Nanjing, China
| | - Richard Hooper
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Gian Luca Di Tanna
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, 2042, Australia.
| |
Collapse
|
8
|
Smit‐Fun VM, Cox PBW, Buhre WF. Role of the anaesthetist in postoperative care. Br J Surg 2020; 107:e8-e10. [PMID: 31903603 PMCID: PMC6973001 DOI: 10.1002/bjs.11395] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 09/18/2019] [Indexed: 11/14/2022]
Abstract
Teamwork
Collapse
Affiliation(s)
- V. M. Smit‐Fun
- Department of Anaesthesia and Pain MedicineMaastricht University Medical Centre, P. Debyelaan 256229HXMaastrichtthe Netherlands
| | - P. B. W. Cox
- Department of Anaesthesia and Pain MedicineMaastricht University Medical Centre, P. Debyelaan 256229HXMaastrichtthe Netherlands
| | - W. F. Buhre
- Department of Anaesthesia and Pain MedicineMaastricht University Medical Centre, P. Debyelaan 256229HXMaastrichtthe Netherlands
- MhenS, School for Mental Health and Neurosciences, University of MaastrichtMaastrichtthe Netherlands
| |
Collapse
|
9
|
[Optimization of perioperative care of high-risk patients-a permanent challenge]. Anaesthesist 2020; 68:651-652. [PMID: 31637497 DOI: 10.1007/s00101-019-0627-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
10
|
Posthuma LM, Visscher MJ, Hollmann MW, Preckel B. Monitoring of High- and Intermediate-Risk Surgical Patients. Anesth Analg 2020; 129:1185-1190. [PMID: 31361670 DOI: 10.1213/ane.0000000000004345] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Linda Maria Posthuma
- From the Department of Anesthesiology, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | | | | | | |
Collapse
|
11
|
Abstract
Abstract
SUMMARY
Large randomized trials provide the highest level of clinical evidence. However, enrolling large numbers of randomized patients across numerous study sites is expensive and often takes years. There will never be enough conventional clinical trials to address the important questions in medicine. Efficient alternatives to conventional randomized trials that preserve protections against bias and confounding are thus of considerable interest. A common feature of novel trial designs is that they are pragmatic and facilitate enrollment of large numbers of patients at modest cost. This article presents trial designs including cluster designs, real-time automated enrollment, and practitioner-preference approaches. Then various adaptive designs that improve trial efficiency are presented. And finally, the article discusses the advantages of embedding randomized trials within registries.
Collapse
|