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Wainwright K, Mayer I, Oliveira Gonçalves AS, Schulz RS, Kiel S, Chenot JF, Flöel A, von Podewils F, Angermaier A, Kurth T. Effect evaluation of a tele-neurologic intervention in primary care in a rural area in Germany-the NeTKoH study protocol of a stepped-wedge cluster randomized trial. BMC Health Serv Res 2023; 23:756. [PMID: 37452372 PMCID: PMC10347790 DOI: 10.1186/s12913-023-09724-w] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/21/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Neurological disorders account for a large and increasing proportion of the global burden of disease. Therefore, it is important to strengthen the management of neurologic care, particularly in rural areas. The use of tele-neurology in primary care in rural areas is internationally considered to have the potential to increase access to health care services and improve the quality of care in these underserved areas. NeTKoH aims to address the existing knowledge gap regarding the effects of a tele-neurologic intervention in primary care under real-world conditions in a rural area in Germany. METHODS NeTKoH is a cluster-randomized controlled trial with a stepped-wedge design involving 33 outpatient general practitioner's (GP) offices (clusters) in a rural area in Northeast Germany. During 11 predetermined steps, all clusters are randomized before they cross over into groups from the control to the intervention arm. The targeted sample size is 1,089 patients with neurologic symptoms that are continuously being recruited. In the intervention arm, tele-neurologic consultations will be provided via a face-to-face video conferencing system with a neurologic expert at a university hospital. The control arm will receive usual care. The primary outcome is the proportion of neurologic problems being solved at the GP's office. Secondary outcomes will comprise hospital stays and days, time until neurologic specialist appointments and diagnostics, patients' health status and quality of life, outpatient and inpatient referrals. A concurrent observational study, together with a process, implementation, and health economic evaluation, will also be conducted. DISCUSSION Using a stepped-wedge cluster design in a real-life situation can help with logistic challenges and enhance the motivation of the participating GPs, as all, at some point, will be in the intervention phase. With the additional implementation evaluation pertaining to external validity, an observational study, and a health economic evaluation, NeTKoH will be able to provide an extensive evaluation for health policy decision-makers regarding the uptake into standard care. TRIAL REGISTRATION German Clinical Trials Register (DRKS00024492). Date registered: September 28, 2021. Date and protocol version: June 2023, version 1.
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Affiliation(s)
- Kerstin Wainwright
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Imke Mayer
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Ricarda S Schulz
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Simone Kiel
- Department of General Practice, Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Jean-François Chenot
- Department of General Practice, Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Agnes Flöel
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Felix von Podewils
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Anselm Angermaier
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Tobias Kurth
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Caille A, Taljaard M, Le Vilain-Abraham F, Le Moigne A, Copas AJ, Tubach F, Dechartres A. Recruitment and implementation challenges were common in stepped-wedge cluster randomized trials: results from a methodological review. J Clin Epidemiol 2022; 148:93-103. [PMID: 35483552 DOI: 10.1016/j.jclinepi.2022.04.024] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/18/2022] [Accepted: 04/20/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To explore challenges in recruitment and intervention implementation in recent stepped-wedge cluster randomized trials (SW-CRTs). STUDY DESIGN AND SETTING We searched PubMed to identify primary reports of SW-CRTs (2019-2020). Two reviewers independently screened studies and extracted data from each report. Recruitment challenge was defined as planned number of clusters or participants not achieved, or any reported changes made to the design to address recruitment difficulties. Implementation challenge was defined as early, late or no implementation of the intervention in at least one cluster. RESULTS Of 55 SW-CRTs, 18 (33%) had a recruitment challenge, 23 (42%) had none, and for 14 (26%) it was impossible to judge. At least one implementation challenge was present in 24 (44%), 8 (15%) had none, and for 23 (42%) it was impossible to judge. Of the 35 (64%) trials with recruitment or implementation challenges, 18 (72%) had one or more modifications of their design, most often a modification of the trial duration. CONCLUSION Investigators must be aware of the risks of recruitment or implementation challenges when considering use of a SW-CRT design. Mitigating strategies should be adopted when planning the trial. More transparent reporting of planned and actual design features is required.
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Affiliation(s)
- Agnes Caille
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Paris, France; Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France; INSERM CIC 1415, CHRU de Tours, Tours, France.
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Floriane Le Vilain-Abraham
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France; INSERM CIC 1415, CHRU de Tours, Tours, France
| | - Alexis Le Moigne
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Paris, France
| | - Andrew J Copas
- MRC Clinical Trials Unit at University College London, London, United Kingdom
| | - Florence Tubach
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Paris, France
| | - Agnes Dechartres
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Paris, France
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Pourrat X, Berthy E, Dupuis A, Barbier L, Buchler M, Guillon LG, Monmousseau F, Ruspini E, Salamé E, Houdard SB, Giraudeau B. Implementing a personalized pharmaceutical plan in kidney or liver transplant patients: study protocol for a stepped-wedge cluster randomized trial (GRePH). Trials 2021; 22:782. [PMID: 34749777 PMCID: PMC8573912 DOI: 10.1186/s13063-021-05749-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 03/25/2021] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background Nowadays, the main challenge of transplantation is the improvement of long-term care, aiming at reducing treatment-related complications and at decreasing rejection rates. Patients’ adherence to both treatment and hygienic-dietary measures is mandatory to achieve these objectives. Adherence to immunosuppressive drugs is estimated to be only 70%. We hypothesized that the implementation of a personalized pharmaceutical plan (PPP) would increase adherence and therefore graft survival. Methods/design This study is a stepped-wedge cluster randomized trial with transplantation units defining clusters. Twelve clusters from 10 university hospitals were recruited. All centres started on the same day in the control phase. Every 7 weeks, one centre will switch to the intervention phase and remain there until the end of inclusions. We plan to recruit 1716 kidney and/or liver transplant patients. The intervention phase consists in setting up the PPP: development of the patient’s hospital and community pharmaceutical follow-up. In the hospital, the pharmacist will carry out drug reconciliation upon admission, daily pharmaceutical follow-up of prescriptions and pharmaceutical interviews with the patient in order to explain the modalities of taking immunosuppressive drugs and hygienic-dietary measures. After hospitalization, during the post-transplantation year, pharmaceutical meetings will take place, prior to medical consultations in order to check the patient’s understanding of the prescription, his adherence, to remind them of hygienic-dietary measures and to look for adverse effects. The hospital pharmacist will also be in charge of establishing a close link with the community pharmacist (CP) and general practitioner, especially providing discharge medication reconciliation, an e-learning and a checklist. Moreover, prior to each pharmaceutical consultation, the hospital pharmacist will contact the CP to discuss patient adherence. The primary outcome is adherence to immunosuppressive treatments 1 year post-transplantation assessed by using the BAASIS questionnaire and the health insurance data from the national health data system. A medico-economic study will measure the efficiency of this plan. Discussion GRePH aims to increase adherence of liver and/or kidney transplant patients to their immunosuppressive therapies in order to reduce transplant rejections. To this end, a new clinical pharmacy model, the PPP, will be set up in 10 university hospitals. Trial registration ClinicalTrials.gov NCT04295928. Registered on 5 March 2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05749-w.
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Affiliation(s)
- Xavier Pourrat
- Pharmacy Department, Pharm D, Tours University Hospital, 2 boulevard Tonnelle, 37044, 09, Tours Cedex, France
| | - Elise Berthy
- Pharmacy Department, Pharm D, Tours University Hospital, 2 boulevard Tonnelle, 37044, 09, Tours Cedex, France.
| | - Antoine Dupuis
- Biology-Pharmacy-Public Health Department, University Hospital of Poitiers, 2 rue de la 9 Milétrie, 86021, Poitiers Cedex, France
| | - Louise Barbier
- Digestive Surgery and Liver Transplantation, Tours University Hospital, Tours, France
| | - Matthias Buchler
- Nephrology Department, Tours University Hospital, 2 boulevard Tonnelle, 37044, 09, Tours Cedex, France
| | - Leslie Grammatico Guillon
- Department of Medical Information, Epidemiology and Medical Economy, Tours University Hospital, Tours, France.,INSERM U966, University of Tours, Tours, France
| | - Fanny Monmousseau
- Health-economic Evaluation Unit, University Hospital of Tours, Tours, France.,EA 7505 Education, Ethics, Health, University of Tours, Tours, France
| | - Eric Ruspini
- Regional Union of Healthcare Professionals Pharmacists of the Greater East of France, 4 rue Piroux, Nancy, France
| | - Ephrem Salamé
- Digestive Surgery and Liver Transplantation, Tours University Hospital, Tours, France
| | - Solène Brunet Houdard
- Health-economic Evaluation Unit, University Hospital of Tours, Tours, France.,EA 7505 Education, Ethics, Health, University of Tours, Tours, France
| | - Bruno Giraudeau
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France.,INSERM CIC1415, CHRU de Tours, Tours, France
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Politi MC, Forcino RC, Parrish K, Durand MA, O'Malley AJ, Elwyn G. Cost talk: protocol for a stepped-wedge cluster randomized trial of an intervention helping patients and urologic surgeons discuss costs of care for slow-growing prostate cancer during shared decision-making. Trials 2021; 22:422. [PMID: 34187547 PMCID: PMC8240421 DOI: 10.1186/s13063-021-05369-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/15/2020] [Accepted: 06/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Costs of care are important to patients making cancer treatment decisions, but clinicians often do not feel prepared to discuss treatment costs. We aim to (1) assess the impact of a conversation-based decision aid (Option Grid) containing cost information about slow-growing prostate cancer management options, combined with urologic surgeon training, on the frequency and quality of patient-urologic surgeon cost conversations, and (2) examine the impact of the decision aid and surgeon training on decision quality. METHODS We will conduct a stepped-wedge cluster randomized trial in outpatient urology practices affiliated with a large academic medical center in the USA. We will randomize five urologic surgeons to four intervention sequences and enroll their patients with a first-time diagnosis of slow-growing prostate cancer independently at each period. Primary outcomes include frequency of cost conversations, initiator of cost conversations, and whether or not a referral is made to address costs. These outcomes will be collected by patient report (post-visit survey) and by observation (audio-recorded clinic visits) with consent. Other outcomes include the following: patient-reported decisional conflict post-visit and at 3-month follow-up, decision regret at 3-month follow-up, shared decision-making post-visit, communication post-visit, and financial toxicity post-visit and at 3-month follow-up; clinician-reported attitudes about shared decision-making before and after the study, and feasibility of sustained intervention use. We will use hierarchical regression analysis to assess patient-level outcomes, including urologic surgeon as a random effect to account for clustering of patient participants. DISCUSSION This study evaluates a two-part intervention to improve cost discussions between urologic surgeons and patients when deciding how to manage slow-growing prostate cancer. Establishing the effectiveness of the strategy under study will allow for its replication in other clinical decision contexts. TRIAL REGISTRATION ClinicalTrials.gov NCT04397016 . Registered on 21 May 2020.
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Affiliation(s)
- Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8100, St. Louis, MO, 63110, USA.
| | - Rachel C Forcino
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA
| | - Katelyn Parrish
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8100, St. Louis, MO, 63110, USA
| | - Marie-Anne Durand
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA.,Université Toulouse III Paul Sabatier, Toulouse, France
| | - A James O'Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, NH, USA
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Carney PA, Hatch B, Stock I, Dickinson C, Davis M, Larsen R, Valenzuela S, Marino M, Darden PM, Gunn R, Ferrara L, Fagnan LJ. A stepped-wedge cluster randomized trial designed to improve completion of HPV vaccine series and reduce missed opportunities to vaccinate in rural primary care practices. Implement Sci 2019; 14:30. [PMID: 30866981 PMCID: PMC6417191 DOI: 10.1186/s13012-019-0871-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 01/25/2019] [Accepted: 02/18/2019] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To test the effectiveness of a comprehensive team-based intervention to improve human papillomavirus (HPV) vaccination completion rates and reduce missed opportunities to vaccinate in rural Oregon. DESIGN Stepped-wedge cluster randomized trial. PARTICIPANTS Forty family physicians and pediatricians who are members of the Oregon Rural Practice-based Research Network. INTERVENTION Tailored to individual practice needs, components will include (1) practice facilitation with clinicians, nurses, front office staff, and others who have patient contact to redesign patient care and communication strategies to optimize HPV vaccine series completion; (2) workflow mapping adapted to practice context to support HPV vaccine delivery; (3) a practice improvement model designed to firmly establish reminder and recall systems and then standing orders; (4) education for patients and parents that underscores HPV vaccination is safe, effective, and an important approach for reducing cancer risk; and (5) partnering with community organizations to plan and implement a social marketing campaign on HPV vaccination. MAIN OUTCOME MEASURES Initiation and completion of the HPV vaccine series as well as reduction in rates of missed opportunities to vaccinate derived from Oregon Immunization Program data. TRIAL REGISTRATION ClinicalTrials.govPRS, NCT03604393 : .Trial was registered on July 11, 2018. The first participant was enrolled on September 11, 2018.
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Affiliation(s)
- Patricia A Carney
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd. MC: FM, Portland, OR, 97239, USA.
| | - Brigit Hatch
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd. MC: FM, Portland, OR, 97239, USA
| | - Isabel Stock
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, USA
| | - Caitlin Dickinson
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, USA
| | - Melinda Davis
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, USA
| | - Rex Larsen
- Oregon Immunization Program, Portland, OR, USA
| | - Steele Valenzuela
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Miguel Marino
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd. MC: FM, Portland, OR, 97239, USA.,OHSU & Portland State University School of Public Health, Portland, OR, USA
| | - Paul M Darden
- Oklahoma Child Health Research Network (OCHRN), University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Rose Gunn
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, USA
| | - Laura Ferrara
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, USA
| | - Lyle J Fagnan
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, USA
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Hemming K, Carroll K, Thompson J, Forbes A, Taljaard M. Quality of stepped-wedge trial reporting can be reliably assessed using an updated CONSORT: crowd-sourcing systematic review. J Clin Epidemiol 2019; 107:77-88. [PMID: 30500405 DOI: 10.1016/j.jclinepi.2018.11.017] [Citation(s) in RCA: 3] [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: 07/30/2018] [Revised: 10/03/2018] [Accepted: 11/19/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The Consolidated Standards of Reporting Trials extension for the stepped-wedge cluster randomized trial (SW-CRT) is a recently published reporting guideline for SW-CRTs. We assess the quality of reporting of a recent sample of SW-CRTs. STUDY DESIGN AND SETTING Quality of reporting was asssessed according to the 26 items in the new guideline using a novel crowd sourcing methodology conducted independently and in duplicate, with random assignment, by 50 reviewers. We assessed reliability of the quality assessments, proposing this as a novel way to assess robustness of items in reporting guidelines. RESULTS Several items were well reported. Some items were very poorly reported, including several items that have unique requirements for the SW-CRT, such as the rationale for use of the design, description of the design, identification and recruitment of participants within clusters, and concealment of cluster allocation (not reported in more than 50% of the reports). Agreement across items was moderate (median percentage agreement was 76% [IQR 64 to 86]). Agreement was low for several items including the description of the trial design and why trial ended or stopped for example. CONCLUSIONS When reporting SW-CRTs, authors should pay particular attention to ensure clear reporting on the exact format of the design with justification, as well as how clusters and individuals were identified for inclusion in the study, and whether this was done before or after randomization of the clusters, which are crucial for risk of bias assessments. Some items, including why the trial ended, might either not be relevant to SW-CRTs or might be unclearly described in the statement.
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Affiliation(s)
- Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, Canada
| | - Jennifer Thompson
- Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew Forbes
- Biostatistics, Monash University, Melbourne, Australia
| | - Monica Taljaard
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
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Eichner FA, Groenwold RHH, Grobbee DE, Oude Rengerink K. Systematic review showed that stepped-wedge cluster randomized trials often did not reach their planned sample size. J Clin Epidemiol 2018; 107:89-100. [PMID: 30458261 DOI: 10.1016/j.jclinepi.2018.11.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 07/18/2018] [Revised: 10/15/2018] [Accepted: 11/14/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine how often stepped-wedge cluster randomized controlled trials reach their planned sample size, and what reasons are reported for choosing a stepped-wedge trial design. STUDY DESIGN AND SETTING We conducted a PubMed literature search (period 2012 to 2017) and included articles describing the results of a stepped-wedge cluster randomized trial. We calculated the percentage of studies reaching their prespecified number of participants and clusters, and we summarized the reasons for choosing the stepped-wedge trial design as well as difficulties during enrollment. RESULTS Forty-six individual stepped-wedge studies from a total of 53 articles were included in our review. Of the 35 studies, for which recruitment rate could be calculated, 69% recruited their planned number of participants, with 80% having recruited the planned number of clusters. Ethical reasons were the most common motivation for choosing the stepped-wedge trial design. Most important difficulties during study conduct were dropout of clusters and delayed implementation of the intervention. CONCLUSION About half of recently published stepped-wedge trials reached their planned sample size indicating that recruitment is also a major problem in these trials. Still, the stepped-wedge trial design can yield practical, ethical, and methodological advantages.
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Affiliation(s)
- Felizitas A Eichner
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Rolf H H Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Katrien Oude Rengerink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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Smit-Fun VM, de Korte-de Boer D, Posthuma LM, Stolze A, Dirksen CD, Hollmann MW, Buhre WF, Boer C. TRACE (Routine posTsuRgical Anesthesia visit to improve patient outComE): a prospective, multicenter, stepped-wedge, cluster-randomized interventional study. Trials 2018; 19:586. [PMID: 30367680 PMCID: PMC6204052 DOI: 10.1186/s13063-018-2952-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 04/26/2018] [Accepted: 09/28/2018] [Indexed: 11/22/2022] Open
Abstract
Background Perioperative complications occur in 30–40% of non-cardiac surgical patients and are the leading cause of early postoperative morbidity and mortality. Regular visits by trained health professionals may decrease the incidence of complications and mortality through earlier detection and adequate treatment of complications. Until now, no studies have been performed on the impact of routine postsurgical anesthesia visits on the incidence of postoperative complications and mortality. Methods TRACE is a prospective, multicenter, stepped-wedge cluster randomized interventional study in academic and peripheral hospitals in the Netherlands. All hospitals start simultaneously with a control phase in which standard care is provided. Sequentially, in a randomized order, hospitals cross over to the intervention phase in which patients at risk are routinely followed up by an anesthesia professional at postoperative days 1 and 3, aiming to detect and prevent or treat postoperative complications. We aim to include 5600 adult patients who are at high risk of developing complications. The primary outcome variable is 30-day postoperative mortality. Secondary outcomes include incidence of postoperative complications and postoperative quality of life up to one year following surgery. Statistical analyses will be performed to compare the control and intervention cohorts with multilevel linear and logistic regression models, adjusted for temporal trends and for clusters (hospitals). The time horizon of the economic (cost-effectiveness) evaluation will be 30 days and one year following surgery. Discussion TRACE is the first to study the effects of a routine postoperative visit by an anesthesia healthcare professional on mortality and cost-effectiveness of surgical patients. If the intervention proves to be beneficial for the patient and cost-effective, the stepped-wedge design ensures direct implementation in the participating hospitals. Trial registration Nederlands Trial Register/Netherlands Trial Registration, NTR5506. Registered on 02 December 2015.
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Affiliation(s)
- Valérie M Smit-Fun
- Department of Anaesthesiology & Pain Medicine, Maastricht University Medical Centre +, P. Debeyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Dianne de Korte-de Boer
- Department of Anaesthesiology & Pain Medicine, Maastricht University Medical Centre +, P. Debeyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - Linda M Posthuma
- Department of Anaesthesiology, Academic Medical Centre Amsterdam, Meibergdreef 9 H1Z-132, 1105 AZ, Amsterdam, The Netherlands
| | - Annick Stolze
- Department of Anesthesiology, VU University Medical Centre, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Carmen D Dirksen
- Department of Clinical Epidemiology and Medical Technology, Maastricht University Medical Centre+, Maastricht, The Netherlands.,Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Academic Medical Centre Amsterdam, Meibergdreef 9 H1Z-132, 1105 AZ, Amsterdam, The Netherlands
| | - Wolfgang F Buhre
- Department of Anaesthesiology & Pain Medicine, Maastricht University Medical Centre +, P. Debeyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Christa Boer
- Department of Anesthesiology, VU University Medical Centre, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
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Auld AF, Agizew T, Pals S, Finlay A, Ndwapi N, Boyd R, Alexander H, Mathoma A, Basotli J, Gwebe-Nyirenda S, Shepherd J, Ellerbrock TV, Date A. Implementation of a pragmatic, stepped-wedge cluster randomized trial to evaluate impact of Botswana's Xpert MTB/RIF diagnostic algorithm on TB diagnostic sensitivity and early antiretroviral therapy mortality. BMC Infect Dis 2016; 16:606. [PMID: 27782821 PMCID: PMC5080709 DOI: 10.1186/s12879-016-1905-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 07/12/2016] [Accepted: 10/08/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In 2012, as a pilot for Botswana's national Xpert MTB/RIF (Xpert) rollout plans, intensified tuberculosis (TB) case finding (ICF) activities were strengthened at 22 HIV treatment clinics prior to phased activation of 13 Xpert instruments. Together, the strengthened ICF intervention and Xpert activation are referred to as the "Xpert package". METHODS The evaluation, called the Xpert Package Rollout Evaluation using a Stepped-wedge design (XPRES), has two key objectives: (1) to compare sensitivity of microscopy-based and Xpert-based pulmonary TB diagnostic algorithms in diagnosing sputum culture-positive TB; and (2) to evaluate impact of the "Xpert package" on all-cause, 6-month, adult antiretroviral therapy (ART) mortality. A pragmatic, stepped-wedge cluster-randomized trial design was chosen. The design involves enrollment of three cohorts: (1) cohort R, a retrospective cohort of all study clinic ART enrollees in the 24 months before study initiation (July 31, 2012); (2) cohort A, a prospective cohort of all consenting patients presenting to study clinics after study initiation, who received the ICF intervention and the microscopy-based TB diagnostic algorithm; and (3) cohort B, a prospective cohort of all consenting patients presenting to study clinics after Xpert activation, who received the ICF intervention and the Xpert-based TB diagnostic algorithm. TB diagnostic sensitivity will be compared between TB culture-positive enrollees in cohorts A and B. All-cause, 6-month ART-mortality will be compared between cohorts R and B. With anticipated cohort R, A, and B sample sizes of about 10,131, 1,878, and 4,258, respectively, the study is estimated to have >80 % power to detect differences in pre-versus post-Xpert TB diagnostic sensitivity if pre-Xpert sensitivity is ≤52.5 % and post-Xpert sensitivity ≥82.5 %, and >80 % power to detect a 40 % reduction in all-cause, 6-month, ART mortality between cohorts R and B if cohort R mortality is ≥13/100 person-years. DISCUSSION Only one small previous trial (N = 424) among ART enrolees in Zimbabwe evaluated, in a secondary analysis, Xpert impact on all-cause 6-month ART mortality. No mortality impact was observed. This Botswana trial, with its larger sample size and powered specifically to detect differences in all-cause 6-month ART mortality, remains well-positioned to contribute understanding of Xpert impact. TRIAL REGISTRATION Retrospectively registered at ClinicalTrials.gov: NCT02538952 .
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Affiliation(s)
- Andrew F Auld
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA.
| | - Tefera Agizew
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana
| | - Sherri Pals
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Alyssa Finlay
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana.,Division of TB Elimination, National Center for HIV, Hepatitis and STD Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Ndwapi Ndwapi
- Ministerial Strategy Office, Ministry of Health, 24 Amos Street, Gaborone, Botswana
| | - Rosanna Boyd
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana.,Division of TB Elimination, National Center for HIV, Hepatitis and STD Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Heather Alexander
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Anikie Mathoma
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana
| | - Joyce Basotli
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana
| | - Sambayawo Gwebe-Nyirenda
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana
| | - James Shepherd
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana.,Yale University School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA
| | - Tedd V Ellerbrock
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Anand Date
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA
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