Recruitment of patients into an internet-based clinical trials database: the experience of OncoLink and the National Colorectal Cancer Research Alliance

A bilingual, Internet-based, targeted advertising campaign for prostate cancer clinical trials: Assessing the feasibility, acceptability, and efficacy of a novel recruitment strategy

BACKGROUND

To address limitations in recruitment and enrollment of diverse, low-literacy patients into prostate cancer clinical trials, we evaluated the feasibility, acceptability, and efficacy of an English and Spanish, Internet-based, multilevel recruitment intervention.

METHODS

Intervention components included (1) a low-literacy, bilingual, automated, Internet-based clinical trial matching tool; (2) a bilingual nurse who assisted individuals with questions and enrollment; and (3) a targeted, Internet-based advertising campaign. We evaluated (a) completion of matching tool, (b) expression of interest in a clinical trial, (c) number of patients who matched to clinical trials at a single institution, (d) discussion of risks and benefits of clinical trials (via follow-up interviews), and (e) effect of the advertising on completing the matching tool. Feasibility, acceptability, and preliminary estimates of efficacy were measured through user engagement with the matching tool and subsequent qualitative interviews with these same users.

RESULTS

During the 28-week study period, 523 users provided demographic information, 263 were identified with prostate cancer, 192 (73%) matched to at least one clinical trial, and 29 (15.1%) of those who matched provided contact information. During the study period, 17 prostate cancer clinical trials were available for matching. We completed follow-up interviews with 14 of the 29 men who provided contact information. Of the 14, 85.7% discussed the risks and benefits of clinical trials with their physician, and 35.7% enrolled in a clinical trial. The Internet-based advertising campaign resulted in an increased number of matching tool completions.

CONCLUSIONS

Our study demonstrates that an Internet-based clinical trial matching tool that is advertised using a targeted Internet-based campaign can provide an effective means to reach diverse, low-literacy patients. When implemented at scale and over a longer duration, such interventions may help increase trial participation among underrepresented populations.

Stepwise strategies to successfully recruit diabetes patients in a large research study in Mexican population

AIMS

Describe stepwise strategies (electronic chart review, patient preselection, call-center, personnel dedicated to recruitment) for the successful recruitment of >5000 type 2 diabetes patients in four months.

METHODS

Twenty-five family medicine clinics from Mexico City and the State of Mexico participated: 13 usual care, 6 specialized diabetes care and 6 chronic disease care. Appointments were scheduled from 11/3/2015 to 3/31/2016. Phone calls were generated automatically from an electronic database. A telephone questionnaire verified inclusion criteria, and scheduled an appointment, with a daily report of appointments, patient attendance, acceptance rate, and questionnaire completeness. Another recruitment log reviewed samples collected. Absolute number (percentage) of patients are reported. Means and standard deviations were estimated for continuous variables, χ² test and independent "t" tests were used. OR and 95% CI were estimated.

RESULTS

14,358 appointments were scheduled, 9146 (63.7%) attended their appointment: 5710 (62.4%) fulfilled inclusion criteria and 5244 agreed to participate (91.8% acceptance). Those accepting participation were more likely women, younger and with longer disease duration (p<0.05). The cost of the call-center service was $3,010,000.00 Mexican pesos (∼$31.70 USD per recruited patient).

CONCLUSIONS

Stepwise strategies recruit a high number of patients in a short time. Call centers offer a low cost per patient.

Implementing point of care "e-referrals" in 137 clinics to increase access to a quit smoking internet system: the Quit-Primo and National Dental PBRN HI-QUIT Studies

Integrating electronic referral systems into clinical practices may increase use of web-accessible tobacco interventions. We report on our feasibility evaluation of using theory-driven implementation science techniques to translate an e-referral system (ReferASmoker.org) into the workflow of 137 community-based medical and dental practices, including system use, patient registration, implementation costs, and lessons learned. After 6 months, 2,376 smokers were e-referred (medical, 1,625; dental, 751). Eighty-six percent of the medical practices [75/87, mean referral = 18.7 (SD = 17.9), range 0-105] and dental practices [43/50, mean referral = 15.0 (SD = 10.5), range 0-38] had e-referred. Of those smokers e-referred, 25.3 registered [mean smoker registration rate-medical 4.9 (SD = 7.6, range 0-59), dental 3.6 (SD = 3.0, range 0-10)]. Estimated mean implementation costs are medical practices, US$429.00 (SD = 85.3); and dental practices, US$238.75 (SD = 13.6). High performing practices reported specific strategies to integrate ReferASmoker.org; low performers reported lack of smokers and patient disinterest in the study. Thus, a majority of practices e-referred and 25.3 % of referred smokers registered demonstrating e-referral feasibility. However, further examination of the identified implementation barriers is important as of the estimated 90,000 to 140,000 smokers seen in the 87 medical practices in 6 months, only 1,625 were e-referred.

eTACTS: a method for dynamically filtering clinical trial search results

OBJECTIVE

Information overload is a significant problem facing online clinical trial searchers. We present eTACTS, a novel interactive retrieval framework using common eligibility tags to dynamically filter clinical trial search results.

MATERIALS AND METHODS

eTACTS mines frequent eligibility tags from free-text clinical trial eligibility criteria and uses these tags for trial indexing. After an initial search, eTACTS presents to the user a tag cloud representing the current results. When the user selects a tag, eTACTS retains only those trials containing that tag in their eligibility criteria and generates a new cloud based on tag frequency and co-occurrences in the remaining trials. The user can then select a new tag or unselect a previous tag. The process iterates until a manageable number of trials is returned. We evaluated eTACTS in terms of filtering efficiency, diversity of the search results, and user eligibility to the filtered trials using both qualitative and quantitative methods.

RESULTS

eTACTS (1) rapidly reduced search results from over a thousand trials to ten; (2) highlighted trials that are generally not top-ranked by conventional search engines; and (3) retrieved a greater number of suitable trials than existing search engines.

DISCUSSION

eTACTS enables intuitive clinical trial searches by indexing eligibility criteria with effective tags. User evaluation was limited to one case study and a small group of evaluators due to the long duration of the experiment. Although a larger-scale evaluation could be conducted, this feasibility study demonstrated significant advantages of eTACTS over existing clinical trial search engines.

CONCLUSION

A dynamic eligibility tag cloud can potentially enhance state-of-the-art clinical trial search engines by allowing intuitive and efficient filtering of the search result space.

Who participates in Web-assisted tobacco interventions? The QUIT-PRIMO and National Dental Practice-Based Research Network Hi-Quit studies

INTRODUCTION

Smoking is the most preventable cause of death. Although effective, Web-assisted tobacco interventions are underutilized and recruitment is challenging. Understanding who participates in Web-assisted tobacco interventions may help in improving recruitment.

OBJECTIVES

To understand characteristics of smokers participating in a Web-assisted tobacco intervention (Decide2Quit.org).

METHODS

In addition to the typical Google advertisements, we expanded Decide2Quit.org recruitment to include referrals from medical and dental providers. We assessed how the expanded recruitment of smokers changed the users' characteristics, including comparison with a population-based sample of smokers from the national Behavioral Risk Factors Surveillance Survey (BRFSS). Using a negative binomial regression, we compared demographic and smoking characteristics by recruitment source, in particular readiness to quit and association with subsequent Decide2Quit.org use.

RESULTS

The Decide2Quit.org cohort included 605 smokers; the 2010 BRFSS dataset included 69,992. Compared to BRFSS smokers, a higher proportion of Decide2Quit.org smokers were female (65.2% vs 45.7%, P=.001), over age 35 (80.8% vs 67.0%, P=.001), and had some college or were college graduates (65.7% vs 45.9%, P=.001). Demographic and smoking characteristics varied by recruitment; for example, a lower proportion of medical- (22.1%) and dental-referred (18.9%) smokers had set a quit date or had already quit than Google smokers (40.1%, P<.001). Medical- and dental-referred smokers were less likely to use Decide2Quit.org functions; in adjusted analysis, Google smokers (predicted count 17.04, 95% CI 14.97-19.11) had higher predicted counts of Web page visits than medical-referred (predicted count 12.73, 95% CI 11.42-14.04) and dental-referred (predicted count 11.97, 95% CI 10.13-13.82) smokers, and were more likely to contact tobacco treatment specialists.

CONCLUSIONS

Recruitment from clinical practices complimented Google recruitment attracting smokers less motivated to quit and less experienced with Web-assisted tobacco interventions.

Assessing the impact of user-centered research on a clinical trial eHealth tool via counterbalanced research design

OBJECTIVE

Informatics applications have the potential to improve participation in clinical trials, but their design must be based on user-centered research. This research used a fully counterbalanced experimental design to investigate the effect of changes made to the original version of a website, http://BreastCancerTrials.org/, and confirm that the revised version addressed and reinforced patients' needs and expectations.

DESIGN

Participants included women who had received a breast cancer diagnosis within the last 5 years (N=77). They were randomized into two groups: one group used and reviewed the original version first followed by the redesigned version, and the other group used and reviewed them in reverse order.

MEASUREMENTS

The study used both quantitative and qualitative measures. During use, participants' click paths and general reactions were observed. After use, participants were asked to answer survey items and open-ended questions to indicate their reactions and which version they preferred and met their needs and expectations better.

RESULTS

Overall, the revised version of the site was preferred and perceived to be clearer, easier to navigate, more trustworthy and credible, and more private and safe overall. However, users who viewed the original version last had similar attitudes toward both versions.

CONCLUSION

By applying research findings to the redesign of a website for clinical trial searching, it was possible to re-engineer the interface to better support patients' decisions to participate in clinical trials. The mechanisms of action in this case appeared to revolve around creating an environment that supported a sense of personal control and decisional autonomy.

The Brustkrebs-Studien.de website for breast cancer patients: User acceptance of a German internet portal offering information on the disease and treatment options, and a clinical trials matching service

Background

The internet portal http://www.brustkrebs-studien.de (BKS) was launched in 2000 by the German Society of Senology (DGS) and the Baden-Württemberg Institute for Women's Health (IFG) to provide expert-written information on breast cancer online and to encourage and facilitate the participation of breast cancer patients in clinical trials. We describe the development of BKS and its applications, and report on website statistics and user acceptance.

Methods

Existing registries, including ClinicalTrials.gov, were analysed before we designed BKS, which combines a trial registry, a knowledge portal, and an online second opinion service. An advisory board guided the process. Log files and patient enquiries for trial participation and second opinions were analysed. A two-week user satisfaction survey was conducted online.

Results

During 10/2005-06/2010, the portal attracted 702,655 visitors, generating 15,507,454 page views. By 06/2010, the website's active scientific community consisted of 189 investigators and physicians, and the registry covered 163 clinical trial protocols. In 2009, 143 patients requested trial enrolment and 119 sought second opinions or individual treatment advice from the expert panel. During the two-week survey in 2008, 5,702 BKS visitors submitted 507 evaluable questionnaires. Portal acceptance was high. Respondents trusted information correctness (80%), welcomed self-matching to clinical trials (79%) and planned to use the portal in the future (76%) and recommend it to others (81%).

Conclusions

BKS is an established and trusted breast cancer information platform offering up-to-date resources and protocols to the growing physician and patient community to encourage participation in clinical trials. Further studies are needed to assess potential increases in trial enrolment by eligibility matching services.

Patient internet use surrounding cancer clinical trials: clinician perceptions and responses

Clinician perceptions of patient internet use related to clinical trials are not well documented. This exploratory study surveyed how cancer care providers at one NCI-designated cancer center viewed patient internet use surrounding cancer trials, including whether it affected patient decision making regarding trial enrollment. The sample included 20 oncologists (59%) and 14 (41%) nurses (n=34). Most clinicians (n=26; 76%) perceived the internet as having an effect on whether or not patients decided to enroll in a cancer trial. Two thirds (n=17; 65%) felt that this effect was positive, including in terms of enhancing patient knowledge of, access to, and enrollment in trials. Clinicians were asked if they ever discussed with their patients the topic of going online to find out more about cancer trials. Over half (n=18; 58%) who responded (n=31) to this item said yes; the rest (n=13; 42%) said no. The majority (n=10; 77%) in the "no" category were among those who reported that the internet had an effect on patient decision making. These data provisionally suggest that clinicians may see the internet as having mostly a positive effect on patient decision making about cancer trials, but that their communication efforts with patients do not always logically follow from this perception. Provider-patient discussion about internet use may be an opportunity for clinicians to contribute to improved patient knowledge of and enrollment in cancer trials. More research is needed to confirm and explain the gap between clinician perception and communication regarding trial-related internet use by cancer patients.

Online cancer communication: meeting the literacy, cultural and linguistic needs of diverse audiences

OBJECTIVE

This article provides an analysis of issues and empirical evidence related to literacy, cultural, and linguistic factors in online health and cancer communication, and recommendations to improve cancer communication for diverse audiences.

METHODS

We examined English-language online literature and selected books and policy documents related to literacy, cultural, and linguistic factors in health and cancer communication.

RESULTS

Studies about literacy, cultural, and linguistic factors in online cancer communication for diverse audiences are limited, but have increased during the past 15 years. Empirical evidence and theoretical guidance describe the critical importance of these factors, significant unmet needs among low-literate, multicultural and non-English-speaking populations, and strategies to improve communication.

CONCLUSION

Overall, online cancer communication has not met the literacy, cultural, and linguistic needs of diverse populations. The literature offers valuable recommendations about enhancing research, practice, and policy for better cancer communication.

PRACTICE IMPLICATIONS

Practitioners should understand the strengths and weaknesses of online cancer communication for vulnerable groups, guide patients to better Websites, and supplement that information with oral and tailored communication.

Clinical trial resources on the internet must be designed to reach underrepresented minorities

PURPOSE

Internet-based clinical trial information services are being developed to increase recruitment to studies. However, there are limited data that evaluate their ability to reach elderly and underrepresented minority populations. This study was designed to evaluate the ability of an established clinical trials registry to reach these populations based on expected Internet use.

PATIENTS AND METHODS

This study compares general Internet users to participants who enrolled in an Internet based colorectal cancer clinical trials registry established by OncoLink (www.oncolink.org) and the National Colorectal Cancer Research Alliance. Observed rates of demographic groupings were compared to those established for general Internet users.

RESULTS

Two thousand, four hundred and thirty-seven participants from the continental United States used the Internet to register for the database. New England, the Mid-Atlantic region, and the Southeast had the highest relative frequency of participation in the database, whereas the Upper Midwest, California, and the South had the lowest rates. Compared to general Internet users, there was an overrepresentation of women (73% vs. 50%) and participants over 55 years old (27% vs. 14%). However, there was an underrepresentation of minorities (10.3% vs. 22%), particularly African Americans (3.1% vs. 8%) and Hispanics (2.8% vs. 9%).

DISCUSSION

The Internet is a growing medium for registry into clinical trials databases. However, even taking into account the selection bias of Internet accessibility, there are still widely disparate demographics between general Internet users and those registering for clinical trials, particularly the underrepresentation of minorities. Internet-based educational and recruitment services for clinical trials must be designed to reach these underrepresented minorities to avoid selection biases in future clinical trials.

Severe traumatic brain injury in Austria I: introduction to the study

OBJECTIVES

The goals of the Austrian Severe Traumatic Brain Injury Study were to investigate the current management of patients with severe traumatic brain injury in Austria and to assess the effects of introducing guidelines for the management of severe traumatic brain injury upon the outcome of these patients. The purpose of this paper is to give a detailed description of the goals, methods, and overall results of the study, and to provide an introduction to a series of papers where the results of the study will be presented and discussed.

STUDY DESIGN

The study included patients with severe traumatic brain injury from five centers in Austria. Data on accident, pre-hospital treatment, hospital treatment, and patient status were collected prospectively. Patient data was entered daily for the first 10 days in hospital and then up to a year after discharge from intensive care. All data was entered into an internet-based database. The data was evaluated to describe epidemiology, pre-hospital treatment, medical management, and surgical management; the evaluation also assessed the effects of guideline-based management on traumatic brain injury patients.

RESULTS

The data set comprises a total of 492 patient records from the 5 participating hospitals; this data was collected over a 3-year period. Data quality is considered good; the number of missing data items is low. ICU mortality was 31.6%. Final outcome: 23% of the patients had a good recovery, 10% had moderate disabilities, 8% had severe disabilities, 6% were persistent vegetative, and 38% died. Final outcome was unknown in 16% of patients.

CONCLUSIONS

This study proved that an internet-based database may be a valuable tool for prospective multicenter studies if many variables have to be collected for a high number of patients. The results of our study provide enough evidence to initiate further research on many aspects of the management of traumatic brain injury patients.

Internet communities for recruitment of cancer patients into an Internet survey: a discussion paper

The purpose of this paper is to provide future directions for the usage of Internet communities (ICs) for recruitment of research participants based on issues raised in an Internet survey among 132 cancer patients. About 317 general and 233 ethnic-specific Internet Cancer Support Groups and 1588 ethnic-specific ICs were contacted to recruit cancer patients. Research staff recorded issues and wrote memos during the recruitment process. The written memos and records were later analyzed using content analysis. The issues included: (a) difficulty in identifying appropriate ICs and potential participants, (b) meta-tags, (c) dominant white and women groups, (d) dynamics inside ICs, (e) difficulty in trust building, and (f) potential selection bias. The findings suggest that researchers thoroughly review the ICs' information, be recognizant of potential gender and ethnic issues and current trends in Internet interaction, and consider potential selection bias.

The Influence of Race on the Attitudes of Radiation Oncology Patients Towards Clinical Trial Enrollment

OBJECTIVES

Enrollment of adult cancer patients in clinical trials remains low, particularly in the minority population. Understanding patient attitudes towards clinical trials during the recruitment process may enhance accrual. Unfortunately, data describing patient attitudes towards clinical trials are limited, particularly in the radiation oncology clinic setting.

METHODS

A piloted questionnaire assessing basic demographics and attitudes toward clinical trials was offered in 2 radiation oncology clinics between April 2003 and October 2003. The questionnaire was completed by 166 patients. The mean age of the patients completing the questionnaire was 56 years (range, 15-84 years). Of the 166 patients included in the analysis, 108 (65%) were White. The most common cancer diagnoses included prostate (19%), head and neck (16%), and breast (14%).

RESULTS

There was no statistical difference between Whites and non-Whites regarding their interest in learning about clinical trials (84.3% versus 84.9%, P = 0.92); nor was there a significant difference in the rate of previous or current trial enrollment (21.3% versus 34.0%, P = 0.08). White patients were more likely to gather information about clinical trials from the Internet (30.6% versus 11.3%, P = 0.007), and they were more likely to use physicians as a source of this information (50.0% versus 34.0%, P = 0.05). Non-White patients were more likely to obtain information about clinical trials from other patients (24.5% versus 12.0%, P = 0.04). In addition, more non-White patients believed they had been treated on clinical trials without their knowledge (21.6% versus 9.3%, P = 0.032). Patients differed somewhat in their expectations of clinical trials. More non-Whites indicated that they would need a >50% chance of benefiting from a trial (64.4% versus 45.0%, P = 0.03) to enroll on that trial, though there were no statistical differences in outlook towards potential toxicities associated with treatment on a clinical trial.

CONCLUSIONS

Minority patients historically enroll in clinical trials at a significantly lower rate. Our study of radiation oncology patients documents significant differences in attitudes towards clinical trials between Whites and non-Whites. Understanding the differences in attitudes may allow physicians to overcome barriers that would otherwise hinder the enrollment of non-White patients into clinical trials.

Breast cancer patients' attitudes toward clinical trials in the radiation oncology clinic versus those searching for trial information on the Internet

Web-based clinical trials matching systems including breast cancer patients are expanding rapidly. However, limited data exist regarding the demographics and attitudes of breast cancer patients using the Internet to search for clinical trials information. Biases in patient populations could be introduced by recruiting patients to trials through the Internet. This study was designed to compare breast cancer patients in the radiation oncology clinic to those using the Internet to search for clinical trials information. A piloted questionnaire assessing demographics and attitudes regarding clinical trials was offered through the radiation oncology clinic at the University of Pennsylvania and on the OncoLink website (http://www.oncolink.org). The questionnaire consisted of 18 questions and was answered by a total of 157 patients with breast cancer. Breast cancer patients using the Web were more likely to be interested in clinical trials testing new drugs or therapies (71 [53%] versus 4 [17%], p = 0.002). More clinic patients indicated they would need a greater than 50% chance of benefiting from a trial (12 [52%] versus 33 [25%], p = 0.01) and a less than 10% potential for serious toxicity from a trial (15 [65%] versus 51 [38%], p = 0.02) for consideration of enrollment. African Americans were more likely than other races to have never used the Internet to search for cancer-related information (4 [40%] versus 18 [12%], p = 0.01), more likely to indicate that they need a greater than 50% chance of benefit to enroll in clinical trials (8 [80%] versus 37 [25%], p = 0.001), and less likely to be interested in clinical trials testing new drugs or therapies (1 [10%] versus 73 [50%], p = 0.01). Breast cancer patients have different attitudes regarding clinical trials based on race, Internet usage, and previous trial enrollment. Biases may be introduced with recruitment for clinical trials through the Internet. Radiation oncologists must consider these issues when offering clinical trials information through the Internet.

An Internet-based cancer clinical trials matching resource

Background

Many patients are now accessing the Internet to obtain cancer clinical trials information. However, services offering clinical trials recruitment information have not been well defined.

Objectives

This study describes one of the first Web-based cancer clinical trials matching resources and the demographics of users who were successfully matched.

Methods

OncoLink is the Internet-based educational resource managed by the University of Pennsylvania Cancer Center (UPCC) and serves between 1 and 2 million pages per month to over 385000 unique IP addresses. OncoLink launched one of the first clinical trials matching resources on the Internet that allowed patients to enter demographic data through a secure connection and be matched to clinical trials. For patients with matches to potential trials, appointments were facilitated with the principal investigators.

Results

While we did not keep track of patients who could not be matched, 627 patients who submitted online applications between January 2002 and April 2003 were successfully matched for potential enrollment in clinical trials. The mean age of the patient population was 56 years (range 18–88 years). Males represented 60% of the patient population, and over 90% of users were Caucasian. Most of the applications were from patients with colorectal cancer (13%), lung cancer (14%), melanoma (10%), and non-Hodgkin's lymphoma (9%).

Conclusions

This report shows that a significant number of patients are willing to use the Internet for enrolling in clinical trials. Care must be taken to reach patients from a variety of socioeconomic and racial backgrounds. This Internet resource helps to facilitate a consultation with a cancer patient who is prescreened and motivated to enroll in clinical trials.