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Boyd CM, Shetterly SM, Powers JD, Weffald LA, Green AR, Sheehan OC, Reeve E, Drace ML, Norton JD, Maiyani M, Gleason KS, Sawyer JK, Maciejewski ML, Wolff JL, Kraus C, Bayliss EA. Evaluating the Safety of an Educational Deprescribing Intervention: Lessons from the Optimize Trial. Drugs Aging 2024; 41:45-54. [PMID: 37982982 PMCID: PMC11101016 DOI: 10.1007/s40266-023-01080-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Patients, family members, and clinicians express concerns about potential adverse drug withdrawal events (ADWEs) following medication discontinuation or fears of upsetting a stable medical equilibrium as key barriers to deprescribing. Currently, there are limited methods to pragmatically assess the safety of deprescribing and ascertain ADWEs. We report the methods and results of safety monitoring for the OPTIMIZE trial of deprescribing education for patients, family members, and clinicians. METHODS This was a pragmatic cluster randomized trial with multivariable Poisson regression comparing outcome rates between study arms. We conducted clinical record review and adjudication of sampled records to assess potential causal relationships between medication discontinuation and outcomes. This study included adults aged 65+ with dementia or mild cognitive impairment, one or more additional chronic conditions, and prescribed 5+ chronic medications. The intervention included an educational brochure on deprescribing that was mailed to patients prior to primary care visits, a clinician notification about individual brochure mailings, and an educational tip sheets was provided monthly to primary care clinicians. The outcomes of the safety monitoring were rates of hospitalizations and mortality during the 4 months following brochure mailings and results of record review and adjudication. The adjudication process was conducted throughout the trial and included classifications: likely, possibly, and unlikely. RESULTS There was a total of 3012 (1433 intervention and 1579 control) participants. There were 420 total hospitalizations involving 269 (18.8%) people in the intervention versus 517 total hospitalizations involving 317 (20.1%) people in the control groups. Adjusted risk ratios comparing intervention to control groups were 0.92 [95% confidence interval (CI) 0.72, 1.16] for hospitalization and 1.19 (95% CI 0.67, 2.11) for mortality. Both groups had zero deaths "likely" attributed to a medication change prior to the event. A total of 3 out of 30 (10%) intervention group hospitalizations and 7 out of 35 (20%) control group hospitalizations were considered "likely" due to a medication change. CONCLUSIONS Population-based deprescribing education is safe in the older adult population with cognitive impairment in our study. Pragmatic methods for safety monitoring are needed to further inform deprescribing interventions. TRIAL REGISTRATION NCT03984396. Registered on 13 June 2019.
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Affiliation(s)
- Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Veterans Affairs Medical Center, Durham, NC, USA.
| | - Susan M Shetterly
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - John D Powers
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Linda A Weffald
- Department of Clinical Pharmacy, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Orla C Sheehan
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Emily Reeve
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Science, University of South Australia, Adelaide, SA, Australia
| | - Melanie L Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jonathan D Norton
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mahesh Maiyani
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Kathy S Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jennifer K Sawyer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Matthew L Maciejewski
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University Medical Center, Durham, NC, USA
| | - Jennifer L Wolff
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Courtney Kraus
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Zahrieh D, Croghan IT, Inselman JW, Mandrekar SJ. Guidelines for Data and Safety Monitoring in Pragmatic Randomized Clinical Trials Using Case Studies. Mayo Clin Proc 2023; 98:1712-1726. [PMID: 37923529 PMCID: PMC10807861 DOI: 10.1016/j.mayocp.2023.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 01/18/2023] [Accepted: 02/23/2023] [Indexed: 11/07/2023]
Abstract
Pragmatic randomized clinical trials (pRCTs) have a unique set of considerations for data and safety monitoring. Because of their unconventional trial designs coupled with collection of multilevel data and implementation outcomes in real-world settings, thoughtful consideration is needed on the presentation of the trial design and accruing data to facilitate review and decision-making by the trial's data and safety monitoring board (DSMB). To our knowledge, there is limited information available in practical guidelines for generalists and medical general practitioners on what to monitor and to report to the DSMB during the conduct of pRCTs and what the DSMB should focus on in its review of reports. This article discusses these matters in the context of 3 case studies focusing on a set of critical data and safety monitoring questions that would be of interest to the generalist conducting pRCTs. In considering these questions, we provide tabular and graphical illustrations of how data can be presented to the DSMB while drawing attention to those areas that the DSMB should focus on in its review of the trial. The strategies and viewpoints discussed herein provide practical guidelines and can serve as a resource for the generalist conducting pRCTs.
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Affiliation(s)
- David Zahrieh
- Department of Data Sciences and Development Strategy, Ultragenyx Pharmaceutical, Novato, CA; Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN.
| | - Ivana T Croghan
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN; Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Jonathan W Inselman
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
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Berdahl CT, Henreid AJ, Cohen TN, Coleman BL, Seferian EG, Leang D, Kim S, Diniz MA, Grissinger M, Kaiser K, McCleskey S, Zhu X, Nuckols TK. Comparing the Safety Action Feedback and Engagement (SAFE) Loop with an established incident reporting system: Study protocol for a pragmatic cluster randomized controlled trial. Contemp Clin Trials Commun 2023; 35:101192. [PMID: 37538195 PMCID: PMC10393596 DOI: 10.1016/j.conctc.2023.101192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/30/2023] [Accepted: 07/15/2023] [Indexed: 08/05/2023] Open
Abstract
Background Incident reporting is widely used in hospitals to improve patient safety, but current reporting systems do not function optimally. The utility of incident reports is limited because hospital staff may not know what to report, may fear retaliation, and may doubt whether administrators will review reports and respond effectively. Methods This is a clustered randomized controlled trial of the Safety Action Feedback and Engagement (SAFE) Loop, an intervention designed to transform hospital incident reporting systems into effective tools for improving patient safety. The SAFE Loop has six key attributes: obtaining nurses' input about which safety problems to prioritize on their unit; focusing on learning about selected high-priority events; training nurses to write more informative event reports; prompting nurses to report high-priority events; integrating information about events from multiple sources; and providing feedback to nurses on findings and mitigation plans. The study will focus on medication errors and randomize 20 nursing units at a large academic/community hospital in Los Angeles. Outcomes include: (1) incident reporting practices (rates of high-priority reports, contributing factors described in reports), (2) nurses' attitudes toward incident reporting, and (3) rates of high-priority events. Quantitative analyses will compare changes in outcomes pre- and post-implementation between the intervention and control nursing units, and qualitative analyses will explore nurses' experiences with implementation. Conclusion If effective, SAFE Loop will have several benefits: increasing nurses' engagement with reporting, producing more informative reports, enabling safety leaders to understand problems, designing system-based solutions more effectively, and lowering rates of high-priority patient safety events.
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Affiliation(s)
- Carl T. Berdahl
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Andrew J. Henreid
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
- University of Connecticut Department of Psychological Sciences, Bousfield Psychology Building, 406 Babbidge Road, Unit 1020, Storrs, CT, 06269-1020, USA
| | - Tara N. Cohen
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Bernice L. Coleman
- Nursing Research, Brawerman Nursing Institute, Cedars-Sinai Medical Center, 6500 Wilshire Boulevard, Los Angeles, CA, 90048, USA
| | - Edward G. Seferian
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Donna Leang
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Sungjin Kim
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Marcio A. Diniz
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
| | - Matthew Grissinger
- Institute for Safe Medication Practices, 5200 Butler Pike, Plymouth Meeting, PA, 19462, USA
| | - Karen Kaiser
- Feinberg School of Medicine, Northwestern University, 625 N Michigan Ave, Chicago, IL, 60611, USA
| | - Sara McCleskey
- RAND Corporation, 1776 Main St, Santa Monica, CA, 90401, USA
| | - Xi Zhu
- Fielding School of Public Health, UCLA, 650 Charles E. Young Dr. South, Los Angeles, CA, 90095, USA
| | - Teryl K. Nuckols
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA, 90048, USA
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Hill RM, Hussain Z, Vieyra B, Gallagher A. Reporting Ethical Procedures in Suicide Prevention Research: Current Status and Recommendations. Arch Suicide Res 2023; 27:1373-1390. [PMID: 36415164 DOI: 10.1080/13811118.2022.2131493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Ethical concerns frequently arise in suicide prevention research regarding participant safety and confidentiality. Despite a substantial literature on managing and navigating ethical concerns in suicide research, little attention has been paid to the reporting of ethical procedures. Furthermore, standard procedures for reporting ethical risk management procedures have not been developed. METHOD A review of the current literature was performed to examine the current state of reporting of ethical procedures within suicide research. Articles published in 2020 (N = 263) from three suicide-focused publications were screened and then coded (n = 131) to identify reporting of procedures for the ethical conduct of research and suicide risk management steps taken by the research teams. RESULTS The majority of articles reported ethical review or approval (84.7%) and reported the use of an informed consent process (77.9%). Only 28.2% included risk mitigation procedures. Of those 29.7% of those articles reported conducting risk evaluation, 66.7% reported resource dissemination, and 51.4% reported an intervention. CONCLUSION As empirical support for brief interventions accrues, suicide prevention researchers should consider establishing standards for the reporting of procedures to ensure the safety of participants with suicidal risk.HighlightsReporting suicide safety protocols helps ensure high ethical standards in research.Fewer than 1/3 of articles reviewed reported risk mitigation procedures in 2020.Standard procedures for reporting safety protocols in suicide research are needed.
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Bunning BJ, Hedlin H, Chen JH, Ciolino JD, Ferstad JO, Fox E, Garcia A, Go A, Johari R, Lee J, Maahs DM, Mahaffey KW, Opsahl-Ong K, Perez M, Rochford K, Scheinker D, Spratt H, Turakhia MP, Desai M. The evolving role of data & safety monitoring boards for real-world clinical trials. J Clin Transl Sci 2023; 7:e179. [PMID: 37745930 PMCID: PMC10514684 DOI: 10.1017/cts.2023.582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/20/2023] [Accepted: 06/24/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction Clinical trials provide the "gold standard" evidence for advancing the practice of medicine, even as they evolve to integrate real-world data sources. Modern clinical trials are increasingly incorporating real-world data sources - data not intended for research and often collected in free-living contexts. We refer to trials that incorporate real-world data sources as real-world trials. Such trials may have the potential to enhance the generalizability of findings, facilitate pragmatic study designs, and evaluate real-world effectiveness. However, key differences in the design, conduct, and implementation of real-world vs traditional trials have ramifications in data management that can threaten their desired rigor. Methods Three examples of real-world trials that leverage different types of data sources - wearables, medical devices, and electronic health records are described. Key insights applicable to all three trials in their relationship to Data and Safety Monitoring Boards (DSMBs) are derived. Results Insight and recommendations are given on four topic areas: A. Charge of the DSMB; B. Composition of the DSMB; C. Pre-launch Activities; and D. Post-launch Activities. We recommend stronger and additional focus on data integrity. Conclusions Clinical trials can benefit from incorporating real-world data sources, potentially increasing the generalizability of findings and overall trial scale and efficiency. The data, however, present a level of informatic complexity that relies heavily on a robust data science infrastructure. The nature of monitoring the data and safety must evolve to adapt to new trial scenarios to protect the rigor of clinical trials.
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Affiliation(s)
- Bryan J. Bunning
- Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Haley Hedlin
- Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
| | - Jonathan H. Chen
- Stanford Center for Biomedical Informatics Research, Stanford University, Stanford, CA, USA
| | - Jody D. Ciolino
- Department of Preventative Medicine – Biostatistics, Northwestern University, Chicago, IL, USA
| | | | - Emily Fox
- Department of Statistics, Stanford University, Stanford, CA, USA
- Kaiser Permanente Northern California Division of Research, Kaiser Permanente, Oakland, CA, USA
| | - Ariadna Garcia
- Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
| | - Alan Go
- Department of Computer Science, Stanford University, Stanford, CA, USA
| | - Ramesh Johari
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - Justin Lee
- Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
| | - David M. Maahs
- Department of Pediatrics, Stanford Medicine Children’s Hospital, Stanford, CA, USA
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research, Stanford University, Stanford, CA, USA
| | - Krista Opsahl-Ong
- Department of Pediatrics, Stanford Medicine Children’s Hospital, Stanford, CA, USA
| | - Marco Perez
- Department of Medicine, Cardiovascular Medicine, Stanford Medicine, Stanford, CA, USA
| | - Kaylin Rochford
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA
| | - David Scheinker
- Systems Design and Collaborative Research, Stanford Medicine Children’s Hospital, Stanford, CA, USA
| | - Heidi Spratt
- Department of Preventative Medicine & Community Health, University of Texas Medical Branch, Galveston, TX, USA
| | - Mintu P. Turakhia
- Stanford Center for Clinical Research, Stanford University, Stanford, CA, USA
| | - Manisha Desai
- Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
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Fritz JM, Greene T, Brennan GP, Minick K, Lane E, Wegener ST, Skolasky RL. Characterizing modifications to a comparative effectiveness research study: the OPTIMIZE trial-using the Framework for Reporting Adaptations and Modifications to Evidence-based Interventions (FRAME). Trials 2023; 24:137. [PMID: 36823645 PMCID: PMC9947905 DOI: 10.1186/s13063-023-07150-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 02/08/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND The OPTIMIZE trial is a multi-site, comparative effectiveness research (CER) study that uses a Sequential Multiple Assessment Randomized Trial (SMART) designed to examine the effectiveness of complex health interventions (cognitive behavioral therapy, physical therapy, and mindfulness) for adults with chronic low back pain. Modifications are anticipated when implementing complex interventions in CER. Disruptions due to COVID have created unanticipated challenges also requiring modifications. Recent methodologic standards for CER studies emphasize that fully characterizing modifications made is necessary to interpret and implement trial results. The purpose of this paper is to outline the modifications made to the OPTIMIZE trial using the Framework for Reporting Adaptations and Modifications to Evidence-Based Interventions (FRAME) to characterize modifications to the OPTIMIZE trial in response to the COVID pandemic and other challenges encountered. METHODS The FRAME outlines a strategy to identify and report modifications to evidence-based interventions or implementation strategies, whether planned or unplanned. We use the FRAME to characterize the process used to modify the aspects of the OPTIMIZE trial. Modifications were made to improve lower-than-anticipated rates of treatment initiation and COVID-related restrictions. Contextual modifications were made to permit telehealth delivery of treatments originally designed for in-person delivery. Training modifications were made with study personnel to provide more detailed information to potential participants, use motivational interviewing communication techniques to clarify potential participants' motivation and possible barriers to initiating treatment, and provide greater assistance with scheduling of assigned treatments. RESULTS Modifications were developed with input from the trial's patient and stakeholder advisory panels. The goals of the modifications were to improve trial feasibility without compromising the interventions' core functions. Modifications were approved by the study funder and the trial steering committee. CONCLUSIONS Full and transparent reporting of modifications to clinical trials, whether planned or unplanned, is critical for interpreting the trial's eventual results and considering future implementation efforts. TRIAL REGISTRATION ClinicalTrials.gov NCT03859713. Registered on March 1, 2019.
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Affiliation(s)
- Julie M. Fritz
- grid.223827.e0000 0001 2193 0096Department of Physical Therapy & Athletic Training, University of Utah, 383 Colorow Drive, Room 391, Salt Lake City, UT 84108 USA
| | - Tom Greene
- grid.223827.e0000 0001 2193 0096Department of Population Health Sciences, University of Utah, Salt Lake City, UT USA
| | - Gerard P. Brennan
- grid.420884.20000 0004 0460 774XRehabilitation Services, Intermountain Healthcare, Salt Lake City, UT USA
| | - Kate Minick
- grid.420884.20000 0004 0460 774XRehabilitation Services, Intermountain Healthcare, Salt Lake City, UT USA
| | - Elizabeth Lane
- grid.223827.e0000 0001 2193 0096Department of Physical Therapy & Athletic Training, University of Utah, 383 Colorow Drive, Room 391, Salt Lake City, UT 84108 USA
| | - Stephen T. Wegener
- grid.21107.350000 0001 2171 9311Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD USA
| | - Richard L. Skolasky
- grid.21107.350000 0001 2171 9311Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD USA ,grid.21107.350000 0001 2171 9311Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD USA
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Engstrom A, Moloney K, Nguyen J, Parker L, Roberts M, Moodliar R, Russo J, Wang J, Scheuer H, Zatzick D. A Pragmatic Clinical Trial Approach to Assessing and Monitoring Suicidal Ideation: Results from A National US Trauma Care System Study. Psychiatry 2021; 85:13-29. [PMID: 34932440 PMCID: PMC8916972 DOI: 10.1080/00332747.2021.1991200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Few investigations have comprehensively described methods for assessing and monitoring suicidal ideation in pragmatic clinical trials of mental health services interventions. This investigation's goal was to assess a collaborative care intervention's effectiveness in reducing suicidal ideation and describe suicide monitoring implementation in a nationwide protocol. METHOD The investigation was a secondary analysis of a stepped wedge cluster randomized trial at 25-Level I trauma centers. Injury survivors (N = 635) were randomized to control (n = 370) and intervention (n = 265) conditions and assessed at baseline hospitalization and follow-up at 3-, 6- and 12-months post-injury. The Patient Health Questionnaire (PHQ-9) item-9 was used to evaluate patients for suicidal ideation. Mixed model regression was used to assess intervention versus control group changes in PHQ-9 item-9 scores over time and associations between baseline characteristics and development of suicidal ideation longitudinally. As part of the study implementation process assessment, suicide outreach call logs were also reviewed. RESULTS Over 50% of patients endorsed suicidal ideation at ≥1 assessment. Intervention patients relative to control patients demonstrated reductions in endorsements of suicidal ideation that did not achieve statistical significance (F[3,1461] = 0.74, P = .53). The study team completed outreach phone calls, texts or voice messages to 268 patients with PHQ-9 item-9 scores ≥1 (n = 161 control, n = 107 intervention). CONCLUSIONS Suicide assessment and monitoring can be feasibly implemented in large-scale pragmatic clinical trials. Intervention patients demonstrated less suicidal ideation over time; however, these comparisons did not achieve statistical significance. Intensive pragmatic trial monitoring may mask treatment effects by providing control patients a supportive intervention. TRIAL REGISTRATION ClinicalTrials.gov NCT02655354.
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Affiliation(s)
- Allison Engstrom
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
| | - Kathleen Moloney
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
| | - Jefferson Nguyen
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
| | - Lea Parker
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
- Department of Psychology, Drexel University College of Arts and Sciences, Philadelphia, US
| | - Michelle Roberts
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, USA
| | - Rddhi Moodliar
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
- Department of Psychology, University of California, Los Angeles, USA
| | - Joan Russo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
| | - Jin Wang
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
- Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle, USA
| | - Hannah Scheuer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
- School of Social Work, University of Washington, Seattle, USA
| | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
- Harborview Injury Prevention and Research Center, University of Washington School of Medicine, Seattle, USA
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Morain SR, Mathews DJH, Weinfurt K, May E, Bollinger JM, Geller G, Sugarman J. Stakeholder perspectives regarding pragmatic clinical trial collateral findings. Learn Health Syst 2021; 5:e10245. [PMID: 34667872 PMCID: PMC8512737 DOI: 10.1002/lrh2.10245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 08/03/2020] [Accepted: 08/16/2020] [Indexed: 12/14/2022] Open
Abstract
CONTEXT Pragmatic clinical trials (PCTs), which are becoming widespread since they are relatively inexpensive and offer important benefits for healthcare decision-making, can also present practical, ethical, and legal challenges. One such challenge involves managing "pragmatic clinical trial collateral findings" (PCT-CFs), or information emerging in a PCT that is unrelated to the primary research question(s), yet may have implications for individual patients, clinicians, or health care systems from whom or within which data were collected. The expansion of PCTs makes it likely healthcare systems will increasingly encounter PCT-CFs, yet little guidance exists regarding their appropriate management. METHODS We conducted semi-structured interviews with key stakeholders experienced in the conduct or oversight of PCTs and those in health system leadership. Interviews explored respondents' experience with PCTs and PCT-CFs, and actual or hypothetical reactions to PCT-CF management. We used standard methods of qualitative analysis to identify key themes. FINDINGS Forty-one stakeholders participated. Four key themes emerged. First, discussions of PCT-CFs are complicated by layers of ambiguity related to both the nature of PCTs themselves, and unanticipated results that emanate from them. Second, management of PCT-CFs is context-specific, and not amenable to a "one-size-fits-all" approach. Third, there was a wide diversity of attitudes regarding the scope of researcher responsibilities in PCTs. Fourth, PCT-CFs had generally not been previously considered by respondents, but there was widespread belief in the importance of prospective planning to anticipate such issues in future PCTs. CONCLUSIONS PCT-CFs are likely to increase, yet those charged with PCT-CF decision-making and their disclosure are unlikely to have experience with these issues. Further deliberation about the ethical obligations and implementation processes regarding PCT-CFs is needed. To enhance the likelihood of developing sound policies and practices, such deliberations should include the input and perspectives of key stakeholders in PCTs, including professionals, policy makers, and patients.
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Affiliation(s)
- Stephanie R. Morain
- Center for Medical Ethics and Health PolicyBaylor College of MedicineHoustonTexasUSA
| | - Debra J. H. Mathews
- Berman Institute of BioethicsJohns Hopkins UniversityBaltimoreMarylandUSA
- Department of PediatricsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Kevin Weinfurt
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Elizabeth May
- Berman Institute of BioethicsJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Juli M. Bollinger
- Berman Institute of BioethicsJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Gail Geller
- Berman Institute of BioethicsJohns Hopkins UniversityBaltimoreMarylandUSA
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Jeremy Sugarman
- Berman Institute of BioethicsJohns Hopkins UniversityBaltimoreMarylandUSA
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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9
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Olsen MH, Hansen ML, Safi S, Jakobsen JC, Greisen G, Gluud C. Central data monitoring in the multicentre randomised SafeBoosC-III trial - a pragmatic approach. BMC Med Res Methodol 2021; 21:160. [PMID: 34332547 PMCID: PMC8325420 DOI: 10.1186/s12874-021-01344-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/08/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Data monitoring of clinical trials is a tool aimed at reducing the risks of random errors (e.g. clerical errors) and systematic errors, which include misinterpretation, misunderstandings, and fabrication. Traditional 'good clinical practice data monitoring' with on-site monitors increases trial costs and is time consuming for the local investigators. This paper aims to outline our approach of time-effective central data monitoring for the SafeBoosC-III multicentre randomised clinical trial and present the results from the first three central data monitoring meetings. METHODS The present approach to central data monitoring was implemented for the SafeBoosC-III trial, a large, pragmatic, multicentre, randomised clinical trial evaluating the benefits and harms of treatment based on cerebral oxygenation monitoring in preterm infants during the first days of life versus monitoring and treatment as usual. We aimed to optimise completeness and quality and to minimise deviations, thereby limiting random and systematic errors. We designed an automated report which was blinded to group allocation, to ease the work of data monitoring. The central data monitoring group first reviewed the data using summary plots only, and thereafter included the results of the multivariate Mahalanobis distance of each centre from the common mean. The decisions of the group were manually added to the reports for dissemination, information, correcting errors, preventing furture errors and documentation. RESULTS The first three central monitoring meetings identified 156 entries of interest, decided upon contacting the local investigators for 146 of these, which resulted in correction of 53 entries. Multiple systematic errors and protocol violations were identified, one of these included 103/818 randomised participants. Accordingly, the electronic participant record form (ePRF) was improved to reduce ambiguity. DISCUSSION We present a methodology for central data monitoring to optimise quality control and quality development. The initial results included identification of random errors in data entries leading to correction of the ePRF, systematic protocol violations, and potential protocol adherence issues. Central data monitoring may optimise concurrent data completeness and may help timely detection of data deviations due to misunderstandings or fabricated data.
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Affiliation(s)
- Markus Harboe Olsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Mathias Lühr Hansen
- Department of Neonatology, Juliane Marie Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Sanam Safi
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Institute of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Gorm Greisen
- Department of Neonatology, Juliane Marie Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Institute of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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10
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Wolfenden L, Foy R, Presseau J, Grimshaw JM, Ivers NM, Powell BJ, Taljaard M, Wiggers J, Sutherland R, Nathan N, Williams CM, Kingsland M, Milat A, Hodder RK, Yoong SL. Designing and undertaking randomised implementation trials: guide for researchers. BMJ 2021; 372:m3721. [PMID: 33461967 PMCID: PMC7812444 DOI: 10.1136/bmj.m3721] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Implementation science is the study of methods to promote the systematic uptake of evidence based interventions into practice and policy to improve health. Despite the need for high quality evidence from implementation research, randomised trials of implementation strategies often have serious limitations. These limitations include high risks of bias, limited use of theory, a lack of standard terminology to describe implementation strategies, narrowly focused implementation outcomes, and poor reporting. This paper aims to improve the evidence base in implementation science by providing guidance on the development, conduct, and reporting of randomised trials of implementation strategies. Established randomised trial methods from seminal texts and recent developments in implementation science were consolidated by an international group of researchers, health policy makers, and practitioners. This article provides guidance on the key components of randomised trials of implementation strategies, including articulation of trial aims, trial recruitment and retention strategies, randomised design selection, use of implementation science theory and frameworks, measures, sample size calculations, ethical review, and trial reporting. It also focuses on topics requiring special consideration or adaptation for implementation trials. We propose this guide as a resource for researchers, healthcare and public health policy makers or practitioners, research funders, and journal editors with the goal of advancing rigorous conduct and reporting of randomised trials of implementation strategies.
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Affiliation(s)
- Luke Wolfenden
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Noah M Ivers
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
- Institute for Health Systems Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Department of Family Medicine and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Byron J Powell
- Brown School and School of Medicine, Washington University in St Louis, St Louis, MI, USA
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - John Wiggers
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Rachel Sutherland
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Nicole Nathan
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Christopher M Williams
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Kingsland
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Andrew Milat
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rebecca K Hodder
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
- Hunter New England Population Health, Locked Bag 10, Wallsend, NSW 2287, Australia
| | - Sze Lin Yoong
- Swinburne University of Technology, School of Health Sciences, Faculty Health, Arts and Design, Hawthorn, VIC, Australia
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11
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The role of data and safety monitoring boards in implementation trials: When are they justified? J Clin Transl Sci 2020; 4:229-232. [PMID: 32695494 PMCID: PMC7348012 DOI: 10.1017/cts.2020.19] [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] [Indexed: 12/16/2022] Open
Abstract
The National Institutes of Health requires data and safety monitoring boards (DSMBs) for all phase III clinical trials. The National Heart, Lung and Blood Institute requires DSMBs for all clinical trials involving more than one site and those involving cooperative agreements and contracts. These policies have resulted in the establishment of DSMBs for many implementation trials, with little consideration regarding the appropriateness of DSMBs and/or key adaptations needed by DSMBs to monitor data quality and participant safety. In this perspective, we review the unique features of implementation trials and reflect on key questions regarding the justification for DSMBs and their potential role and monitoring targets within implementation trials.
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