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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Corey L. Behind the Scenes Heroes: The COVID-19 Vaccine Data and Safety Monitoring Board. J Infect Dis 2021; 224:1993-1994. [PMID: 34007981 PMCID: PMC8194659 DOI: 10.1093/infdis/jiab267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 12/02/2022] Open
Affiliation(s)
- Lawrence Corey
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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Palm ME, Lindsell CJ, Selker HP. Sharing data among clinical trials of therapeutics in COVID-19: Barriers and facilitators to collaborating in a crisis. J Clin Transl Sci 2021; 6:e52. [PMID: 35599687 PMCID: PMC9114727 DOI: 10.1017/cts.2021.866] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 09/20/2021] [Accepted: 10/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background The Clinical and Translational Science Award Program (CTSA) Trial Innovation Network (TIN) was launched in 2016 to increase the efficiency and effectiveness of multisite trials by supporting the development of national infrastructure. With the advent of the COVID-19 pandemic, it was therefore well-positioned to support clinical trial collaboration. The TIN was leveraged to support two initiatives: (1) to create and evaluate a mechanism for coordinating Data and Safety Monitoring Board (DSMB) activities among multiple ongoing trials of the same therapeutic agents, and (2) to share data across clinical trials so that smaller, likely underpowered studies, could be combined to produce meaningful and actionable data through pooled analyses. The success of these initiatives was understood to be dependent upon the willingness of investigators, study teams, and US National Institutes of Health research networks to collaborate and share information. Methods To inform these two initiatives, we conducted semistructured interviews with members of CTSA hubs and clinical research stakeholders that probed barriers and facilitators to collaboration. Thematic analysis identified topics relevant across institutions, individuals, and DSMBs. Results The DSMB coordination initiative was viewed as less controversial, while the data pooling initiative was seen as complex because of its potential impact on publication, authorship, and the rewards of discovery. Barriers related to resources, centralization, and technical work were significant, but interviewees suggested these could be handled by the provision of central funding and supportive frameworks. The more intractable findings were related to issues around credit and ownership of data. Conclusion Based on our interviews, we conclude with nine recommended actions that can be implemented to support collaboration.
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Affiliation(s)
- Marisha E. Palm
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts, USA
| | - Christopher J. Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Harry P. Selker
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts, USA
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Shih WJ, Yao C, Xie T. Data Monitoring for the Chinese Clinical Trials of Remdesivir in Treating Patients with COVID-19 During the Pandemic Crisis. Ther Innov Regul Sci 2020; 54:1236-55. [PMID: 32865809 DOI: 10.1007/s43441-020-00159-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 04/29/2020] [Indexed: 01/05/2023]
Abstract
Two phase-III, double-blind, randomized clinical trials of remdesivir plus SOC (standard of care) versus placebo plus SOC have been conducted in Wuhan hospitals by Chinese investigators during the urgent COVID-19 epidemic [ClincalTrials.gov NCT04257656 and NCT04252664]. These trials have been highly anticipated worldwide. We expect investigators of the trials will soon report the clinical and laboratory findings from the medical perspective. This manuscript provides documentary style information on the process of monitoring key data and making recommendations to the sponsor and investigators based on analytical insights when dealing with the emergent situation from the statistical viewpoint. Having monitored data sequentially from 237 patients, we comment on the strength and weakness of the study design and suggest the treatment effect of remdesivir on severe COVID-19 cases. Our experience with using the Dynamic Data Monitoring (DDM) tool has demonstrated its efficiency and reliability in supporting DSMB’s instantaneous review of essential data during the emergent situation. DDM, when used properly by disciplined statisticians, has shown its capability of exploring the trial data flexibly and, in the meantime, protecting the trial’s scientific integrity.
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Stanev R. Quantitative Framework for Retrospective Assessment of Interim Decisions in Clinical Trials. Med Decis Making 2016; 36:999-1010. [PMID: 27353825 PMCID: PMC5046159 DOI: 10.1177/0272989x16655346] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/09/2016] [Indexed: 11/23/2022]
Abstract
This article presents a quantitative way of modeling the interim decisions of clinical trials. While statistical approaches tend to focus on the epistemic aspects of statistical monitoring rules, often overlooking ethical considerations, ethical approaches tend to neglect the key epistemic dimension. The proposal is a second-order decision-analytic framework. The framework provides means for retrospective assessment of interim decisions based on a clear and consistent set of criteria that combines both ethical and epistemic considerations. The framework is broadly Bayesian and addresses a fundamental question behind many concerns about clinical trials: What does it take for an interim decision (e.g., whether to stop the trial or continue) to be a good decision? Simulations illustrating the modeling of interim decisions counterfactually are provided.
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Affiliation(s)
- Roger Stanev
- Department of Philosophy, Ottawa Hospital Research Institute, University of Ottawa, Canada
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Malliaras K, Makkar RR, Smith RR, Cheng K, Wu E, Bonow RO, Marbán L, Mendizabal A, Cingolani E, Johnston PV, Gerstenblith G, Schuleri KH, Lardo AC, Marbán E. Intracoronary cardiosphere-derived cells after myocardial infarction: evidence of therapeutic regeneration in the final 1-year results of the CADUCEUS trial (CArdiosphere-Derived aUtologous stem CElls to reverse ventricUlar dySfunction). J Am Coll Cardiol 2014; 63:110-22. [PMID: 24036024 PMCID: PMC3947063 DOI: 10.1016/j.jacc.2013.08.724] [Citation(s) in RCA: 355] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 07/21/2013] [Accepted: 08/19/2013] [Indexed: 12/14/2022]
Abstract
OBJECTIVES This study sought to report full 1-year results, detailed magnetic resonance imaging analysis, and determinants of efficacy in the prospective, randomized, controlled CADUCEUS (CArdiosphere-Derived aUtologous stem CElls to reverse ventricUlar dySfunction) trial. BACKGROUND Cardiosphere-derived cells (CDCs) exerted regenerative effects at 6 months in the CADUCEUS trial. Complete results at the final 1-year endpoint are unknown. METHODS Autologous CDCs (12.5 to 25 × 10(6)) grown from endomyocardial biopsy specimens were infused via the intracoronary route in 17 patients with left ventricular dysfunction 1.5 to 3 months after myocardial infarction (MI) (plus 1 infused off-protocol 14 months post-MI). Eight patients were followed as routine-care control patients. RESULTS In 13.4 months of follow-up, safety endpoints were equivalent between groups. At 1 year, magnetic resonance imaging revealed that CDC-treated patients had smaller scar size compared with control patients. Scar mass decreased and viable mass increased in CDC-treated patients but not in control patients. The single patient infused 14 months post-MI responded similarly. CDC therapy led to improved regional function of infarcted segments compared with control patients. Scar shrinkage correlated with an increase in viability and with improvement in regional function. Scar reduction correlated with baseline scar size but not with a history of temporally remote MI or time from MI to infusion. The changes in left ventricular ejection fraction in CDC-treated subjects were consistent with the natural relationship between scar size and ejection fraction post-MI. CONCLUSIONS Intracoronary administration of autologous CDCs did not raise significant safety concerns. Preliminary indications of bioactivity include decreased scar size, increased viable myocardium, and improved regional function of infarcted myocardium at 1 year post-treatment. These results, which are consistent with therapeutic regeneration, merit further investigation in future trials. (CArdiosphere-Derived aUtologous stem CElls to reverse ventricUlar dySfunction [CADUCEUS]; NCT00893360).
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MESH Headings
- Aged
- Biopsy
- Coronary Vessels
- Electrocardiography, Ambulatory
- Female
- Follow-Up Studies
- Heart Ventricles/pathology
- Heart Ventricles/physiopathology
- Humans
- Injections, Intra-Arterial
- Magnetic Resonance Imaging, Cine
- Male
- Middle Aged
- Myocardial Infarction/complications
- Myocardial Infarction/physiopathology
- Myocardial Infarction/surgery
- Myocytes, Cardiac/cytology
- Myocytes, Cardiac/transplantation
- Recovery of Function
- Stem Cell Transplantation/methods
- Time Factors
- Transplantation, Autologous
- Treatment Outcome
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Left/surgery
- Ventricular Function, Left/physiology
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Affiliation(s)
| | - Raj R Makkar
- Cedars-Sinai Heart Institute, Los Angeles, California
| | | | - Ke Cheng
- Cedars-Sinai Heart Institute, Los Angeles, California
| | - Edwin Wu
- Division of Cardiology, Department of Medicine, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois
| | - Robert O Bonow
- Division of Cardiology, Department of Medicine, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois
| | - Linda Marbán
- Cedars-Sinai Heart Institute, Los Angeles, California
| | | | | | - Peter V Johnston
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Gary Gerstenblith
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Karl H Schuleri
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Albert C Lardo
- Division of Cardiology, Department of Medicine, The Johns Hopkins University, Baltimore, Maryland; Department of Biomedical Engineering, The Johns Hopkins University, Baltimore, Maryland
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Lechtzin N, West N, Allgood S, Wilhelm E, Khan U, Mayer-Hamblett N, Aitken ML, Ramsey BW, Boyle MP, Mogayzel PJ Jr, Goss CH. Rationale and design of a randomized trial of home electronic symptom and lung function monitoring to detect cystic fibrosis pulmonary exacerbations: the early intervention in cystic fibrosis exacerbation (eICE) trial. Contemp Clin Trials 2013; 36:460-9. [PMID: 24055998 DOI: 10.1016/j.cct.2013.09.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 09/09/2013] [Accepted: 09/13/2013] [Indexed: 01/01/2023]
Abstract
BACKGROUND Acute pulmonary exacerbations are central events in the lives of individuals with cystic fibrosis (CF). Pulmonary exacerbations lead to impaired lung function, worse quality of life, and shorter survival. We hypothesized that aggressive early treatment of acute pulmonary exacerbation may improve clinical outcomes. PURPOSE Describe the rationale of an ongoing trial designed to determine the efficacy of home monitoring of both lung function measurements and symptoms for early detection and subsequent early treatment of acute CF pulmonary exacerbations. STUDY DESIGN A randomized, non-blinded, multi-center trial in 320 individuals with CF aged 14 years and older. The study compares usual care to a twice a week assessment of home spirometry and CF respiratory symptoms using an electronic device with data transmission to the research personnel to identify and trigger early treatment of CF pulmonary exacerbation. Participants will be enrolled in the study for 12 months. The primary endpoint is change in FEV1 (L) from baseline to 12 months determined by a linear mixed effects model incorporating all quarterly FEV1 measurements. Secondary endpoints include time to first acute protocol-defined pulmonary exacerbation, number of acute pulmonary exacerbations, number of hospitalization days for acute pulmonary exacerbation, time from the end of acute pulmonary exacerbation to onset of subsequent pulmonary exacerbation, change in health related quality of life, change in treatment burden, change in CF respiratory symptoms, and adherence to the study protocol. CONCLUSIONS This study is a first step in establishing alternative approaches to the care of CF pulmonary exacerbations. We hypothesize that early treatment of pulmonary exacerbations has the potential to slow lung function decline, reduce respiratory symptoms and improve the quality of life for individuals with CF.
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Bonhoeffer J, Imoukhuede EB, Aldrovandi G, Bachtiar NS, Chan ES, Chang S, Chen RT, Fernandopulle R, Goldenthal KL, Heffelfinger JD, Hossain S, Jevaji I, Khamesipour A, Kochhar S, Makhene M, Malkin E, Nalin D, Prevots R, Ramasamy R, Sellers S, Vekemans J, Walker KB, Wilson P, Wong V, Zaman K, Heininger U. Template protocol for clinical trials investigating vaccines--focus on safety elements. Vaccine 2013; 31:5602-20. [PMID: 23499603 DOI: 10.1016/j.vaccine.2013.02.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [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: 02/14/2013] [Accepted: 02/25/2013] [Indexed: 11/19/2022]
Abstract
This document is intended as a guide to the protocol development for trials of prophylactic vaccines. The template may serve phases I-IV clinical trials protocol development to include safety relevant information as required by the regulatory authorities and as deemed useful by the investigators. This document may also be helpful for future site strengthening efforts.
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Affiliation(s)
- Jan Bonhoeffer
- University Children's Hospital (UKBB), University of Basel, Basel, Switzerland.
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