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Chaccour C, Casellas A, Hammann F, Ruiz-Castillo P, Nicolas P, Montaña J, Mael M, Selvaraj P, Duthaler U, Mrema S, Kakolwa M, Lyimo I, Okumu F, Marathe A, Schürch R, Elobolobo E, Sacoor C, Saute F, Xia K, Jones C, Rist C, Maia M, Rabinovich NR. BOHEMIA: Broad One Health Endectocide-based Malaria Intervention in Africa-a phase III cluster-randomized, open-label, clinical trial to study the safety and efficacy of ivermectin mass drug administration to reduce malaria transmission in two African settings. Trials 2023; 24:128. [PMID: 36810194 PMCID: PMC9942013 DOI: 10.1186/s13063-023-07098-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 01/17/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Residual malaria transmission is the result of adaptive mosquito behavior that allows malaria vectors to thrive and sustain transmission in the presence of good access to bed nets or insecticide residual spraying. These behaviors include crepuscular and outdoor feeding as well as intermittent feeding upon livestock. Ivermectin is a broadly used antiparasitic drug that kills mosquitoes feeding on a treated subject for a dose-dependent period. Mass drug administration with ivermectin has been proposed as a complementary strategy to reduce malaria transmission. METHODS A cluster randomized, parallel arm, superiority trial conducted in two settings with distinct eco-epidemiological conditions in East and Southern Africa. There will be three groups: human intervention, consisting of a dose of ivermectin (400 mcg/kg) administered monthly for 3 months to all the eligible population in the cluster (>15 kg, non-pregnant and no medical contraindication); human and livestock intervention, consisting human treatment as above plus treatment of livestock in the area with a single dose of injectable ivermectin (200 mcg/kg) monthly for 3 months; and controls, consisting of a dose of albendazole (400 mg) monthly for 3 months. The main outcome measure will be malaria incidence in a cohort of children under five living in the core of each cluster followed prospectively with monthly RDTs DISCUSSION: The second site for the implementation of this protocol has changed from Tanzania to Kenya. This summary presents the Mozambique-specific protocol while the updated master protocol and the adapted Kenya-specific protocol undergo national approval in Kenya. BOHEMIA will be the first large-scale trial evaluating the impact of ivermectin-only mass drug administration to humans or humans and cattle on local malaria transmission TRIAL REGISTRATION: ClinicalTrials.gov NCT04966702 . Registered on July 19, 2021. Pan African Clinical Trials Registry PACTR202106695877303.
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Affiliation(s)
- Carlos Chaccour
- ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain. .,Universidda de Navarra, Pamplona, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Madrid, Spain.
| | - Aina Casellas
- grid.434607.20000 0004 1763 3517ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain
| | - Felix Hammann
- grid.411656.10000 0004 0479 0855University Hospital of Bern, Inselspital, Bern, Switzerland
| | - Paula Ruiz-Castillo
- grid.434607.20000 0004 1763 3517ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain
| | - Patricia Nicolas
- grid.434607.20000 0004 1763 3517ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain
| | - Julia Montaña
- grid.434607.20000 0004 1763 3517ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain
| | - Mary Mael
- grid.434607.20000 0004 1763 3517ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain
| | - Prashant Selvaraj
- grid.418309.70000 0000 8990 8592Bill and Melinda Gates Foundation, Seattle, USA
| | - Urs Duthaler
- grid.6612.30000 0004 1937 0642University Basel, Basel, Switzerland
| | - Sigilbert Mrema
- grid.414543.30000 0000 9144 642XIfakara Health Institute, Ifakara, Tanzania
| | - Mwaka Kakolwa
- grid.414543.30000 0000 9144 642XIfakara Health Institute, Ifakara, Tanzania
| | - Issa Lyimo
- grid.414543.30000 0000 9144 642XIfakara Health Institute, Ifakara, Tanzania
| | - Fredros Okumu
- grid.414543.30000 0000 9144 642XIfakara Health Institute, Ifakara, Tanzania
| | - Achla Marathe
- grid.27755.320000 0000 9136 933XUniversity of Virginia, Charlottesville, USA
| | - Roger Schürch
- grid.438526.e0000 0001 0694 4940Virginia Polytechnic Institute and State University, Blacksburg, USA
| | - Eldo Elobolobo
- grid.452366.00000 0000 9638 9567Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
| | - Charfudin Sacoor
- grid.452366.00000 0000 9638 9567Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
| | - Francisco Saute
- grid.452366.00000 0000 9638 9567Centro de Investigação em Saúde de Manhiça, Manhica, Mozambique
| | - Kang Xia
- grid.438526.e0000 0001 0694 4940Virginia Polytechnic Institute and State University, Blacksburg, USA
| | - Caroline Jones
- grid.33058.3d0000 0001 0155 5938KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
| | - Cassidy Rist
- grid.438526.e0000 0001 0694 4940Virginia Polytechnic Institute and State University, Blacksburg, USA
| | - Marta Maia
- grid.33058.3d0000 0001 0155 5938KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
| | - N. Regina Rabinovich
- grid.434607.20000 0004 1763 3517ISGlobal, Barcelona Institute for Global Health, Barcelona, Spain ,grid.38142.3c000000041936754XTH Chan Harvard School of Public Health, Boston, USA
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Watabayashi KK, Bell-Brown A, Kreizenbeck K, Egan K, Lyman GH, Hershman DL, Arnold KB, Bansal A, Barlow WE, Sullivan SD, Ramsey SD. Successes and challenges of implementing a cancer care delivery intervention in community oncology practices: lessons learned from SWOG S1415CD. BMC Health Serv Res 2022; 22:432. [PMID: 35365139 PMCID: PMC8973954 DOI: 10.1186/s12913-022-07835-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/23/2022] [Indexed: 11/12/2022] Open
Abstract
Background Cancer Care Delivery (CCD) research studies often require practice-level interventions that pose challenges in the clinical trial setting. The SWOG Cancer Research Network (SWOG) conducted S1415CD, one of the first pragmatic cluster-randomized CCD trials to be implemented through the National Cancer Institute (NCI) Community Oncology Program (NCORP), to compare outcomes of primary prophylactic colony stimulating factor (PP-CSF) use for an intervention of automated PP-CSF standing orders to usual care. The introduction of new methods for study implementation created challenges and opportunities for learning that can inform the design and approach of future CCD interventions. Methods The order entry system intervention was administered at the site level; sites were affiliated NCORP practices that shared the same chemotherapy order system. 32 sites without existing guideline-based PP-CSF standing orders were randomized to the intervention (n = 24) or to usual care (n = 8). Sites assigned to the intervention participated in tailored training, phone calls and onboarding activities administered by research team staff and were provided with additional funding and external IT support to help them make protocol required changes to their order entry systems. Results The average length of time for intervention sites to complete reconfiguration of their order sets following randomization was 7.2 months. 14 of 24 of intervention sites met their individual patient recruitment target of 99 patients enrolled per site. Conclusions In this paper we share seven recommendations based on lessons learned from implementation of the S1415CD intervention at NCORP community oncology practices representing diverse geographies and patient populations across the U. S. It is our hope these recommendations can be used to guide future implementation of CCD interventions in both research and community settings. Trial Registration NCT02728596, registered April 5, 2016. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07835-4.
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Affiliation(s)
- Kate K Watabayashi
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N. PO Box 19024, Seattle, WA, 98109, USA.
| | - Ari Bell-Brown
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N. PO Box 19024, Seattle, WA, 98109, USA
| | - Karma Kreizenbeck
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N. PO Box 19024, Seattle, WA, 98109, USA
| | - Kathryn Egan
- Amazon, 410 Terry Ave N., Seattle, WA, 98109, USA
| | - Gary H Lyman
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N. PO Box 19024, Seattle, WA, 98109, USA.,School of Medicine, University of Washington, Seattle Cancer Care Alliance, 825 Eastlake Ave East, Seattle, WA, 98109, USA
| | - Dawn L Hershman
- Columbia University Medical Center, 161 Ft. Washington 1068, New York, NY, 10032, USA
| | - Kathryn B Arnold
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N. PO Box 19024, Seattle, WA, 98109, USA.,SWOG Statistics and Data Management Center, 1100 Fairview Ave N., Seattle, WA, 98109, USA
| | - Aasthaa Bansal
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N. PO Box 19024, Seattle, WA, 98109, USA.,CHOICE Institute, School of Pharmacy, University of Washington, University of Washington Health Sciences Building, 1956 NE Pacific St. H362, Seattle, WA, 98195, USA
| | - William E Barlow
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N. PO Box 19024, Seattle, WA, 98109, USA.,SWOG Statistics and Data Management Center, 1100 Fairview Ave N., Seattle, WA, 98109, USA
| | - Sean D Sullivan
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N. PO Box 19024, Seattle, WA, 98109, USA.,CHOICE Institute, School of Pharmacy, University of Washington, University of Washington Health Sciences Building, 1956 NE Pacific St. H362, Seattle, WA, 98195, USA
| | - Scott D Ramsey
- Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N. PO Box 19024, Seattle, WA, 98109, USA.,School of Medicine, University of Washington, Seattle Cancer Care Alliance, 825 Eastlake Ave East, Seattle, WA, 98109, USA
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van der Sluijs R, Fiddelers AAA, Waalwijk JF, Reitsma JB, Dirx MJ, den Hartog D, Evers SMAA, Goslings JC, Hoogeveen WM, Lansink KW, Leenen LPH, van Heijl M, Poeze M. The impact of the Trauma Triage App on pre-hospital trauma triage: design and protocol of the stepped-wedge, cluster-randomized TESLA trial. Diagn Progn Res 2020; 4:10. [PMID: 32566758 PMCID: PMC7302135 DOI: 10.1186/s41512-020-00076-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/22/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Field triage of trauma patients is crucial to get the right patient to the right hospital within a particular time frame. Minimization of undertriage, overtriage, and interhospital transfer rates could substantially reduce mortality rates, life-long disabilities, and costs. Identification of patients in need of specialized trauma care is predominantly based on the judgment of Emergency Medical Services professionals and a pre-hospital triage protocol. The Trauma Triage App is a smartphone application that includes a prediction model to aid Emergency Medical Services professionals in the identification of patients in need of specialized trauma care. The aim of this trial is to assess the impact of this new digital approach to field triage on the primary endpoint undertriage. METHODS The Trauma triage using Supervised Learning Algorithms (TESLA) trial is a stepped-wedge cluster-randomized controlled trial with eight clusters defined as Emergency Medical Services regions. These clusters are an integral part of five inclusive trauma regions. Injured patients, evaluated on-scene by an Emergency Medical Services professional, suspected of moderate to severe injuries, will be assessed for eligibility. This unidirectional crossover trial will start with a baseline period in which the default pre-hospital triage protocol is used, after which all clusters gradually implement the Trauma Triage App as an add-on to the existing triage protocol. The primary endpoint is undertriage on patient and cluster level and is defined as the transportation of a severely injured patient (Injury Severity Score ≥ 16) to a lower-level trauma center. Secondary endpoints include overtriage, hospital resource use, and a cost-utility analysis. DISCUSSION The TESLA trial will assess the impact of the Trauma Triage App in clinical practice. This novel approach to field triage will give new and previously undiscovered insights into several isolated components of the diagnostic strategy to get the right trauma patient to the right hospital. The stepped-wedge design allows for within and between cluster comparisons. TRIAL REGISTRATION Netherlands Trial Register, NTR7243. Registered 30 May 2018, https://www.trialregister.nl/trial/7038.
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Affiliation(s)
- Rogier van der Sluijs
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Audrey A. A. Fiddelers
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Job F. Waalwijk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Johannes B. Reitsma
- Department of Epidemiology, Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Miranda J. Dirx
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dennis den Hartog
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Silvia M. A. A. Evers
- Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - J. Carel Goslings
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Surgery, Onze Lieve Vrouwe Hospital, Amsterdam, The Netherlands
| | | | - Koen W. Lansink
- Department of Surgery, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - Luke P. H. Leenen
- Department of Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Mark van Heijl
- Department of Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands
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Johnson AM, Jones SB, Duncan PW, Bushnell CD, Coleman SW, Mettam LH, Kucharska-Newton AM, Sissine ME, Rosamond WD. Hospital recruitment for a pragmatic cluster-randomized clinical trial: Lessons learned from the COMPASS study. Trials 2018; 19:74. [PMID: 29373987 PMCID: PMC5787294 DOI: 10.1186/s13063-017-2434-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 12/29/2017] [Indexed: 11/10/2022] Open
Abstract
Background Pragmatic randomized clinical trials are essential to determine the effectiveness of interventions in “real-world” clinical practice. These trials frequently use a cluster-randomized methodology, with randomization at the site level. Despite policymakers’ increased interest in supporting pragmatic randomized clinical trials, no studies to date have reported on the unique recruitment challenges faced by cluster-randomized pragmatic trials. We investigated key challenges and successful strategies for hospital recruitment in the Comprehensive Post-Acute Stroke Services (COMPASS) study. Methods The COMPASS study is designed to compare the effectiveness of the COMPASS model versus usual care in improving functional outcomes, reducing the numbers of hospital readmissions, and reducing caregiver strain for patients discharged home after stroke or transient ischemic attack. This model integrates early supported discharge planning with transitional care management, including nurse-led follow-up phone calls after 2, 30, and 60 days and an in-person clinic visit at 7–14 days involving a functional assessment and neurological examination. We present descriptive statistics of the characteristics of successfully recruited hospitals compared with all eligible hospitals, reasons for non-participation, and effective recruitment strategies. Results We successfully recruited 41 (43%) of 95 eligible North Carolina hospitals. Leading, non-exclusive reasons for non-participation included: insufficient staff or financial resources (n = 33, 61%), lack of health system support (n = 16, 30%), and lack of support of individual decision-makers (n = 11, 20%). Successful recruitment strategies included: building and nurturing relationships, engaging team members and community partners with a diverse skill mix, identifying gatekeepers, finding mutually beneficial solutions, having a central institutional review board, sharing published pilot data, and integrating contracts and review board administrators. Conclusions Although we incorporated strategies based on the best available evidence at the outset of the study, hospital recruitment required three times as much time and considerably more staff than anticipated. To reach our goal, we tailored strategies to individuals, hospitals, and health systems. Successful recruitment of a sufficient number and representative mix of hospitals requires considerable preparation, planning, and flexibility. Strategies presented here may assist future trial organizers in implementing cluster-randomized pragmatic trials. Trial registration Clinicaltrials.gov, NCT02588664. Registered on 23 October 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2434-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna M Johnson
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA.
| | - Sara B Jones
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Sylvia W Coleman
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Laurie H Mettam
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA
| | - Anna M Kucharska-Newton
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA
| | - Mysha E Sissine
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA
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Rapp K, Kampe K, Roigk P, Kircheisen H, Becker C, Lindlbauer I, König HH, Rothenbacher D, Büchele G. The osteoporotic fracture prevention program in rural areas (OFRA): a protocol for a cluster-randomized health care fund driven intervention in a routine health care setting. BMC Musculoskelet Disord 2016; 17:458. [PMID: 27821102 PMCID: PMC5100272 DOI: 10.1186/s12891-016-1308-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 10/25/2016] [Indexed: 11/21/2022] Open
Abstract
Background Fragility fractures are one of the leading causes for disability in old people. The main underlying mechanisms are osteoporosis and falls. Evidence-based measures to prevent either falls or fractures are available. However, coordinated preventive approaches combining bone health and fall prevention are rare. The objective of the study is to evaluate a health care fund driven program, which encourages insured persons to adhere to national guidelines regarding bone health and physical activity and falls prevention. The health care fund cooperates with the ‘German Association of Rural Women’ and the ‘German Gymnastics Association’. The program consists of mobility and falls prevention classes, the examination of bone health by a DXA scan, and a consultation about ‘safety in the living environment’. Methods Cluster-randomized study in 47 intervention and 143 control districts in 5 federal states of Germany. The program is offered to a) community-living women and men aged 70 to <85 years with a prior fragility fracture or b) community-living women aged 75 to <80 years. Within two years more than 10,000 persons will be directly contacted and motivated to make use of the components of the program. The primary outcome is a combined measure of incident osteoporotic fractures. Secondary outcomes include the rate of referrals to a mobility and falls prevention class or a bone mass density measurement. An economic evaluation will be conducted. Discussion The study evaluates a complex preventive intervention in a routine health care setting which may serve as model for similar approaches in other areas or countries. Trial registration DRKS-ID: DRKS00009000; date of registration: 06.08.2015
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Affiliation(s)
- Kilian Rapp
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany.
| | - Karin Kampe
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Patrick Roigk
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Hella Kircheisen
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Clemens Becker
- Department of Clinical Gerontology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Ivonne Lindlbauer
- Department of Medical Sociology and Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Dietrich Rothenbacher
- Institute of Epidemiology and Medical Biometry, Ulm University, Helmholtzstr. 22, 89081, Ulm, Germany
| | - Gisela Büchele
- Institute of Epidemiology and Medical Biometry, Ulm University, Helmholtzstr. 22, 89081, Ulm, Germany
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Kahan BC, Doré CJ, Murphy MF, Jairath V. Bias was reduced in an open-label trial through the removal of subjective elements from the outcome definition. J Clin Epidemiol 2016; 77:38-43. [PMID: 27262238 DOI: 10.1016/j.jclinepi.2016.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 04/13/2016] [Accepted: 05/13/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To determine whether modifying an outcome definition to remove subjective elements reduced bias in a trial that could not use blinded outcome assessment. STUDY DESIGN AND SETTING Reanalysis of an open-label trial comparing a restrictive vs. liberal transfusion strategy for gastrointestinal bleeding. The usual definition of the primary outcome, further bleeding, allows subjective clinical symptoms to be used alone for diagnosis, whereas the definition used in the trial required more objective confirmation by endoscopy. We compared treatment effect estimates for these two definitions. RESULTS Fewer subjective symptom-identified events were confirmed using more objective methods in the restrictive arm (18%) than in the liberal arm (56%), indicating differential assessment between arms. An analysis using all events (both subjective and more objective) led to an odds ratio of 0.83 (95% confidence interval [CI]: 0.50-1.37). When only events confirmed using more objective methods were included, the odds ratio was 0.50 (95% CI: 0.32-0.78). The ratio of the odds ratios was 1.66, indicating that including unconfirmed events in the definition biased the treatment effect upward by 66%. CONCLUSION Modifying the outcome definition to exclude subjective elements substantially reduced bias. This may be a useful strategy for reducing bias in trials that cannot blind outcome assessment.
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Affiliation(s)
- Brennan C Kahan
- Pragmatic Clinical Trials Unit, Centre for Primary Care and Public Health, Queen Mary University, 58 Turner Street, E1 2AB London, UK.
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit at UCL, UCL, Gower Street, London WC1E 6BT, UK
| | - Michael F Murphy
- NHS Blood and Transplant, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
| | - Vipul Jairath
- Department of Medicine, Western University and London Health Sciences Network, London, Ontario N6A 5A5, Canada; Nuffield Department of Medicine, University of Oxford, Old Road Campus, Headington, Oxford OX3 7BN, UK
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Nosyk B, Krebs E, Min JE, Ahamad K, Buxton J, Goldsmith C, Hull M, Joe R, Krajden M, Lima VD, Olding M, Wood E, Montaner JSG. The 'Expanded HIV care in opioid substitution treatment' (EHOST) cluster-randomized, stepped-wedge trial: A study protocol. Contemp Clin Trials 2015; 45:201-209. [PMID: 26342295 DOI: 10.1016/j.cct.2015.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/28/2015] [Accepted: 08/30/2015] [Indexed: 11/18/2022]
Abstract
The public health response to HIV/AIDS has turned its focus onto optimizing health care system delivery to maximize case identification, access and sustained engagement in antiretroviral treatment (ART). Opioid Agonist Treatment (OAT) provides a critical opportunity for HIV testing and linkage to ART. The EHOST study is a cluster-randomized, stepped-wedge trial to evaluate a prescriber-focused intervention to increase HIV testing rates, and optimize ART engagement and retention outcomes among individuals engaged in OAT. The study will encompass all drug treatment clinics currently admitting patients for the treatment of opioid use disorder across the province of British Columbia, encompassing an estimated 90% of the OAT caseload. The trial will be executed over a 24-month period, with groups of clinics receiving the intervention in 6-month intervals. Evaluation of the proposed intervention's effectiveness will focus on three primary outcomes: (i) the HIV testing rate among those not known to be HIV positive; (ii) the rate of ART initiation among those not on ART; and (iii) the rate of ART continuation among those on ART. A difference-in-differences analytical framework will be applied to estimate the intervention's effect. This approach will assess site-specific changes in primary outcomes across clusters while adjusting for potential residual heterogeneity in patient case mix, volume, and quality of care across clinics. Statistical analysis of outcomes will be conducted entirely with linked population-level administrative health datasets. Facilitated by established collaborations between key stakeholders across the province, the EHOST intervention promises to optimize HIV testing and care within a marginalized and hard-to-reach population.
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Affiliation(s)
- B Nosyk
- BC Centre for Excellence in HIV/AIDS, Canada; Faculty of Health Sciences, Simon Fraser University, Canada.
| | - E Krebs
- BC Centre for Excellence in HIV/AIDS, Canada
| | - J E Min
- BC Centre for Excellence in HIV/AIDS, Canada
| | - K Ahamad
- BC Centre for Excellence in HIV/AIDS, Canada
| | - J Buxton
- BC Centre for Disease Control and Prevention, Canada; School of Population and Public Health, University of British Columbia, Canada
| | - C Goldsmith
- Faculty of Health Sciences, Simon Fraser University, Canada
| | - M Hull
- BC Centre for Excellence in HIV/AIDS, Canada; Vancouver Coastal Health Authority, Canada
| | - R Joe
- Vancouver Coastal Health Authority, Canada
| | - M Krajden
- BC Centre for Disease Control and Prevention, Canada
| | - V D Lima
- BC Centre for Excellence in HIV/AIDS, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Canada
| | - M Olding
- BC Centre for Excellence in HIV/AIDS, Canada
| | - E Wood
- BC Centre for Excellence in HIV/AIDS, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Canada
| | - J S G Montaner
- BC Centre for Excellence in HIV/AIDS, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Canada
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