1
|
Heward E, Dempsey J, Molloy J, Isba R, Lunn J, Ashcroft DM, Hay AD, Nichani JR, Bruce IA. Outcome measures for use in trials of paediatric otorrhoea: A systematic review. Int J Pediatr Otorhinolaryngol 2024; 176:111820. [PMID: 38103308 DOI: 10.1016/j.ijporl.2023.111820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/24/2023] [Accepted: 12/04/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Paediatric otorrhoea (PO) describes a middle ear infection that results in a perforation of the tympanic membrane and ear discharge, in children and young people (CYP). Prolonged infection may be associated with hearing loss and developmental delay. The current management of paediatric otorrhoea is variable, including non-invasive treatments (conservative, oral antibiotics, topical antibiotics) and surgery, reflecting the lack of a sufficiently strong evidence base. Outcome reporting is fundamental to producing reliable and meaningful evidence to inform best practice. OBJECTIVES Primary objective: to determine which outcome measures are currently used to evaluate treatment success in studies of non-surgical treatments for paediatric otorrhoea. SECONDARY OBJECTIVES to identify outcome measurement instruments used in the literature and assess their applicability for use in clinical trials of PO. METHODS This systematic review was registered with PROSPERO (CRD42023407976). Database searches of EMBASE, MEDLINE and Cochrane was performed on June 6, 2023, covering from Jan 1995 to May 2023. Randomised controlled trials or study protocols involving CYP with PO were included following PRISMA guidelines. Risk of bias was assessed with Cochrane's tool. RESULTS Of the 377 papers identified, six were included in the systematic review. The primary outcome of five of the studies related to otorrhoea cessation; both time to cessation and proportion recovered at various time points were used as measures. Two measurement instruments were identified: Otitis Media-6 Questionnaire and the Institute for Medical Technology Assessment Productivity Cost Questionnaire. Both were shown to be applicable measurement instruments when used in clinical trials of PO. CONCLUSIONS To promote homogeneity and facilitate meaningful comparison and combination of studies, we propose that time to cessation of otorrhoea from onset of otorrhoea should be used as the primary outcome in future studies. Further research is needed to establish if this is the most important outcome to children and their caregivers.
Collapse
Affiliation(s)
- Elliot Heward
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK; Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust, UK.
| | - James Dempsey
- Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust, UK
| | - John Molloy
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK; Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust, UK
| | - Rachel Isba
- Alder Hey Children's NHS Foundation Trust, UK
| | - Judith Lunn
- Lancaster Medical School, Lancaster University, Health Innovation One, Sir John Fisher Drive, Lancaster, UK
| | - Darren M Ashcroft
- Division of Pharmacy & Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK; NIHR Greater Manchester Patient Safety Translational Research Centre (PSTRC), University of Manchester, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Jaya R Nichani
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK; Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust, UK
| | - Iain A Bruce
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK; Royal Manchester Children's Hospital, Manchester University Hospitals NHS Foundation Trust, UK
| |
Collapse
|
2
|
Hullegie S, Venekamp RP, van Dongen TMA, Mulder S, van Schaik W, de Wit GA, Hay AD, Little P, Moore MV, Sanders EAM, Bonten MJM, Bogaert D, Schilder AG, Damoiseaux RAMJ. Topical or oral antibiotics for children with acute otitis media presenting with ear discharge: study protocol of a randomised controlled non-inferiority trial. BMJ Open 2021; 11:e052128. [PMID: 34916313 PMCID: PMC8679066 DOI: 10.1136/bmjopen-2021-052128] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Around 15%-20% of children with acute otitis media present with ear discharge due to a spontaneous tear or perforation of the eardrum (AOMd). Current guidance recommends clinicians to consider oral antibiotics as first-line treatment in this condition. The opening in the eardrum however should allow topical antibiotics to enter the middle ear directly. Local administration of antibiotics does not expose children to systemic side effects and may put less selective resistance pressure on bacteria. Evidence on the effectiveness of this approach in children with AOMd is lacking. METHODS AND ANALYSIS A primary care-based, open, individually randomised, controlled, non-inferiority trial. The trial aims to recruit 350 children aged 6 months to 12 years with AOMd and ear pain and/or fever. Participants will be randomised to 7 days of hydrocortisone-bacitracin-colistin eardrops five drops three times daily or amoxicillin oral suspension 50 mg/kg body weight per day, divided over three doses. Parents will keep a daily diary of AOM symptoms, adverse events and complications for 2 weeks. In addition, they will record AOM recurrences, healthcare utilisation and societal costs for 3 months. The primary outcome is the proportion of children without ear pain and fever at day 3. Secondary outcomes include ear pain and fever intensity/severity; days with ear discharge; eardrum perforation at 2 weeks; adverse events during first 2 weeks; costs; and cost effectiveness at 2 weeks and 3 months. The primary analyses will be intention-to-treat and per-protocol analyses will be conducted as well. ETHICS AND DISSEMINATION The medical research ethics committee Utrecht, The Netherlands has given ethical approval (17-400/G-M). Parents/guardians of participants will provide written informed consent. Study results will be submitted for publication in peer-reviewed medical journals and presented at relevant (inter)national scientific meetings. TRIAL REGISTRATION NUMBER The Netherlands National Trial Register; NTR6723. Date of registration: 27 November 2017.
Collapse
Affiliation(s)
- Saskia Hullegie
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Roderick P Venekamp
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Thijs M A van Dongen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sanne Mulder
- Parent and PPI contributor, Utrecht, the Netherlands
| | - Willem van Schaik
- Institute of Microbiology and Infection, University of Birmingham, Birmingham, UK
| | - G Ardine de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Centre for Nutrition, Prevention and Healthcare, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Population Science and Medical Education, Aldemoor Health Centre, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care Population Science and Medical Education, Aldemoor Health Centre, University of Southampton, Southampton, UK
| | - Elisabeth A M Sanders
- Department of Paediatric Immunology and Infectious Diseases, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Centre for Infectious Disease Control, National Institute of Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Debby Bogaert
- Department of Paediatric Immunology and Infectious Diseases, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
- Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Anne Gm Schilder
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
- evidENT, Ear Institute, University College London, London, UK
| | - Roger A M J Damoiseaux
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
3
|
Hay AD, Moore MV, Taylor J, Turner N, Noble S, Cabral C, Horwood J, Prasad V, Curtis K, Delaney B, Damoiseaux R, Domínguez J, Tapuria A, Harris S, Little P, Lovering A, Morris R, Rowley K, Sadoo A, Schilder A, Venekamp R, Wilkes S, Curcin V. Immediate oral versus immediate topical versus delayed oral antibiotics for children with acute otitis media with discharge: the REST three-arm non-inferiority electronic platform-supported RCT. Health Technol Assess 2021; 25:1-76. [PMID: 34816795 DOI: 10.3310/hta25670] [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: 11/22/2022] Open
Abstract
BACKGROUND Acute otitis media is a painful infection of the middle ear that is commonly seen in children. In some children, the eardrum spontaneously bursts, discharging visible pus (otorrhoea) into the outer ear. OBJECTIVE To compare the clinical effectiveness of immediate topical antibiotics or delayed oral antibiotics with the clinical effectiveness of immediate oral antibiotics in reducing symptom duration in children presenting to primary care with acute otitis media with discharge and the economic impact of the alternative strategies. DESIGN This was a pragmatic, three-arm, individually randomised (stratified by age < 2 vs. ≥ 2 years), non-inferiority, open-label trial, with economic and qualitative evaluations, supported by a health-record-integrated electronic trial platform [TRANSFoRm (Translational Research and Patient Safety in Europe)] with an internal pilot. SETTING A total of 44 English general practices. PARTICIPANTS Children aged ≥ 12 months and < 16 years whose parents (or carers) were seeking medical care for unilateral otorrhoea (ear discharge) following recent-onset (≤ 7 days) acute otitis media. INTERVENTIONS (1) Immediate ciprofloxacin (0.3%) solution, four drops given three times daily for 7 days, or (2) delayed 'dose-by-age' amoxicillin suspension given three times daily (clarithromycin twice daily if the child was penicillin allergic) for 7 days, with structured delaying advice. All parents were given standardised information regarding symptom management (paracetamol/ibuprofen/fluids) and advice to complete the course. COMPARATOR Immediate 'dose-by-age' oral amoxicillin given three times daily (or clarithromycin given twice daily) for 7 days. Parents received standardised symptom management advice along with advice to complete the course. MAIN OUTCOME MEASURE Time from randomisation to the first day on which all symptoms (pain, fever, being unwell, sleep disturbance, otorrhoea and episodes of distress/crying) were rated 'no' or 'very slight' problem (without need for analgesia). METHODS Participants were recruited from routine primary care appointments. The planned sample size was 399 children. Follow-up used parent-completed validated symptom diaries. RESULTS Delays in software deployment and configuration led to small recruitment numbers and trial closure at the end of the internal pilot. Twenty-two children (median age 5 years; 62% boys) were randomised: five, seven and 10 to immediate oral, delayed oral and immediate topical antibiotics, respectively. All children received prescriptions as randomised. Seven (32%) children fully adhered to the treatment as allocated. Symptom duration data were available for 17 (77%) children. The median (interquartile range) number of days until symptom resolution in the immediate oral, delayed oral and immediate topical antibiotic arms was 6 (4-9), 4 (3-7) and 4 (3-6), respectively. Comparative analyses were not conducted because of small numbers. There were no serious adverse events and six reports of new or worsening symptoms. Qualitative clinician interviews showed that the trial question was important. When the platform functioned as intended, it was liked. However, staff reported malfunctioning software for long periods, resulting in missed recruitment opportunities. Troubleshooting the software placed significant burdens on staff. LIMITATIONS The over-riding weakness was the failure to recruit enough children. CONCLUSIONS We were unable to answer the main research question because of a failure to reach the required sample size. Our experience of running an electronic platform-supported trial in primary care has highlighted challenges from which we have drawn recommendations for the National Institute for Health Research (NIHR) and the research community. These should be considered before such a platform is used again. TRIAL REGISTRATION Current Controlled Trials ISRCTN12873692 and EudraCT 2017-003635-10. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 67. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Alastair D Hay
- Centre for Academic Primary Care, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael V Moore
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Jodi Taylor
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicholas Turner
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Christie Cabral
- Centre for Academic Primary Care, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jeremy Horwood
- Centre for Academic Primary Care, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Vibhore Prasad
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kathryn Curtis
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Brendan Delaney
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Roger Damoiseaux
- Julius Center for Health Sciences and Primary Care & Department of Otorhinolaryngology, UMC Utrecht, Utrecht, the Netherlands
| | - Jesús Domínguez
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Archana Tapuria
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Sue Harris
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Andrew Lovering
- Department of Medical Microbiology, North Bristol NHS Trust, Bristol, UK
| | - Richard Morris
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kate Rowley
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Annie Sadoo
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Anne Schilder
- Ear Institute, University College London, London, UK
| | - Roderick Venekamp
- Julius Center for Health Sciences and Primary Care & Department of Otorhinolaryngology, UMC Utrecht, Utrecht, the Netherlands
| | - Scott Wilkes
- School of Medicine, University of Sunderland, Sunderland, UK
| | - Vasa Curcin
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| |
Collapse
|
4
|
Cabral C, Curtis K, Curcin V, Domínguez J, Prasad V, Schilder A, Turner N, Wilkes S, Taylor J, Gallagher S, Little P, Delaney B, Moore M, Hay AD, Horwood J. Challenges to implementing electronic trial data collection in primary care: a qualitative study. BMC FAMILY PRACTICE 2021; 22:147. [PMID: 34229624 PMCID: PMC8259773 DOI: 10.1186/s12875-021-01498-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 06/23/2021] [Indexed: 11/17/2022]
Abstract
Background Within-consultation recruitment to primary care trials is challenging. Ensuring procedures are efficient and self-explanatory is the key to optimising recruitment. Trial recruitment software that integrates with the electronic health record to support and partially automate procedures is becoming more common. If it works well, such software can support greater participation and more efficient trial designs. An innovative electronic trial recruitment and outcomes software was designed to support recruitment to the Runny Ear randomised controlled trial, comparing topical, oral and delayed antibiotic treatment for acute otitis media with discharge in children. A qualitative evaluation investigated the views and experiences of primary care staff using this trial software. Methods Staff were purposively sampled in relation to site, role and whether the practice successfully recruited patients. In-depth interviews were conducted using a flexible topic guide, audio recorded and transcribed. Data were analysed thematically. Results Sixteen staff were interviewed, including GPs, practice managers, information technology (IT) leads and research staff. GPs wanted trial software that automatically captures patient data. However, the experience of getting the software to work within the limited and complex IT infrastructure of primary care was frustrating and time consuming. Installation was reliant on practice level IT expertise, which varied between practices. Although most had external IT support, this rarely included supported for research IT. Arrangements for approving new software varied across practices and often, but not always, required authorisation from Clinical Commissioning Groups. Conclusions Primary care IT systems are not solely under the control of individual practices or CCGs or the National Health Service. Rather they are part of a complex system that spans all three and is influenced by semi-autonomous stakeholders operating at different levels. This led to time consuming and sometimes insurmountable barriers to installation at the practice level. These need to be addressed if software supporting efficient research in primary care is to become a reality. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01498-6.
Collapse
Affiliation(s)
- Christie Cabral
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Kathryn Curtis
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Vasa Curcin
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, Addison House 3.07, Guy's Campus, London, SE1 1UL, UK
| | - Jesús Domínguez
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, Addison House 3.07, Guy's Campus, London, SE1 1UL, UK
| | - Vibhore Prasad
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, Addison House 3.07, Guy's Campus, London, SE1 1UL, UK
| | - Anne Schilder
- NIHR University College London Hospitals Biomedical Research Centre and evidENT, UCL Ear Institute, 91 Gower Street, London, WC1E 6AB, UK
| | - Nicholas Turner
- Bristol Randomised Trial Collaboration (BRTC), Part of the Bristol Trial Centre, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS82PS, UK
| | - Scott Wilkes
- School of Medicine, Faculty of Health Sciences and Wellbeing, University of Sunderland, Sciences Complex, City Campus, Chester Road, Sunderland, SR1 3SD, UK
| | - Jodi Taylor
- Bristol Randomised Trial Collaboration (BRTC), Part of the Bristol Trial Centre, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS82PS, UK
| | - Sarah Gallagher
- The Portland Practice, St Pauls Medical Centre, 121 Swindon Road, Cheltenham, GL50 4DP, Gloucestershire, UK
| | - Paul Little
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University Of Southampton, Southampton, SO17 1BJ, UK
| | - Brendan Delaney
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - Michael Moore
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University Of Southampton, Southampton, SO17 1BJ, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Jeremy Horwood
- Centre for Academic Primary Care, Bristol Medical School: Population Health Sciences, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| |
Collapse
|