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Gaugler JE, Baier RR, Baker ZG, Boltz M, Fortinsky RH, Gustavson AM, Hodgson NA, Jutkowitz E, McPhillips MV, Parker LJ, Sefcik JS, Gitlin LN. Using Hybrid Effectiveness Studies to Facilitate Implementation in Community-Based Settings: Three Case Studies in Dementia Care Research. J Am Med Dir Assoc 2024; 25:27-33. [PMID: 37643720 PMCID: PMC10840611 DOI: 10.1016/j.jamda.2023.07.025] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 07/27/2023] [Accepted: 07/30/2023] [Indexed: 08/31/2023]
Abstract
The pipeline from discovery to testing and then implementing evidence-based innovations in real-world contexts may take 2 decades or more to achieve. Implementation science innovations, such as hybrid studies that combine effectiveness and implementation research questions, may help to bridge the chasm between intervention testing and implementation in dementia care. This paper describes hybrid effectiveness studies and presents 3 examples of dementia care interventions conducted in various community-based settings. Studies that focus on outcomes and implementation processes simultaneously may result in a truncated and more efficient implementation pipeline, thereby providing older persons, their families, health care providers, and communities with the best evidence to improve quality of life and care more rapidly. We offer post-acute and long-term care researchers considerations related to study design, sampling, data collection, and analysis that they can apply to their own dementia and other chronic disease care investigations.
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Affiliation(s)
- Joseph E Gaugler
- School of Public Health, University of Minnesota, Minneapolis, MN, USA; College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA.
| | - Rosa R Baier
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA; Center for Long-Term Care Quality & Innovation and Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Zachary G Baker
- School of Public Health, University of Minnesota, Minneapolis, MN, USA; College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA
| | - Marie Boltz
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA; Ross and Carol Nese College of Nursing, The Pennsylvania State University, University Park, PA, USA
| | - Richard H Fortinsky
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA; UConn Center on Aging, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Allison M Gustavson
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Administration Healthcare System, Minneapolis, MN, USA; Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA; National Institute on Aging (NIA) IMbedded Pragmatic Alzheimer's Disease (AD) and AD-Related Dementias (AD/ADRD) Clinical Trials (IMPACT) Collaboratory Implementation Core, Providence, RI, USA
| | - Nancy A Hodgson
- National Institute on Aging (NIA) IMbedded Pragmatic Alzheimer's Disease (AD) and AD-Related Dementias (AD/ADRD) Clinical Trials (IMPACT) Collaboratory Implementation Core, Providence, RI, USA; Biobehavioral Health Sciences Department, University of Pennsylvania, Philadelphia, PA, USA
| | - Eric Jutkowitz
- Center for Long-Term Care Quality & Innovation and Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; National Institute on Aging (NIA) IMbedded Pragmatic Alzheimer's Disease (AD) and AD-Related Dementias (AD/ADRD) Clinical Trials (IMPACT) Collaboratory Implementation Core, Providence, RI, USA
| | - Miranda V McPhillips
- National Institute on Aging (NIA) IMbedded Pragmatic Alzheimer's Disease (AD) and AD-Related Dementias (AD/ADRD) Clinical Trials (IMPACT) Collaboratory Implementation Core, Providence, RI, USA; School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Lauren J Parker
- National Institute on Aging (NIA) IMbedded Pragmatic Alzheimer's Disease (AD) and AD-Related Dementias (AD/ADRD) Clinical Trials (IMPACT) Collaboratory Implementation Core, Providence, RI, USA; Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Justine S Sefcik
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA; National Institute on Aging (NIA) IMbedded Pragmatic Alzheimer's Disease (AD) and AD-Related Dementias (AD/ADRD) Clinical Trials (IMPACT) Collaboratory Implementation Core, Providence, RI, USA
| | - Laura N Gitlin
- College of Nursing and Health Professions, Drexel University, Philadelphia, PA, USA; National Institute on Aging (NIA) IMbedded Pragmatic Alzheimer's Disease (AD) and AD-Related Dementias (AD/ADRD) Clinical Trials (IMPACT) Collaboratory Implementation Core, Providence, RI, USA
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2
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Savage JS, Moore AM, Kling SMR, Marini M, Hernandez E, Franceschelli Hosterman J, Hassink S, Paul IM, Bailey-Davis L. Coordination Between Primary Care and Women, Infants, and Children to Prevent Obesity for Infants from Low-Income Families: A Pragmatic Randomized Clinical Trial. Child Obes 2023; 19:515-524. [PMID: 36367983 DOI: 10.1089/chi.2022.0137] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Rapid weight gain during infancy is associated with risk for later obesity, yet little research to date has examined the effect of a responsive parenting (RP) intervention with care coordination between pediatric primary care providers and Women, Infants, and Children nutritionists on infant weight. Methods: The Women, Infants, and Children Enhancements to Early Healthy Lifestyles for Baby (WEE Baby) Care study is a pragmatic, randomized clinical trial for mothers and infants (n = 288) designed to examine the effect of a patient-centered RP intervention that used advanced health information technology strategies to coordinate care to reduce rapid infant weight gain compared with standard care. General linear models examined intervention effects on infant conditional weight gain scores, weight-for-age z scores, BMI, and overweight status (BMI-for-age ≥85th percentile) from birth to age 6 months, and mothers' use of food to soothe from age 2 to 6 months. Results: There were no intervention effects on infant conditional weight gain scores or overweight status at 6 months. Infants in the RP intervention had lower mean weight-for-age z scores [M = -0.04, standard error (SE) = 0.04 vs. M = 0.05, SE = 0.04; p = 0.008] and lower mean BMI (M = 16.05, SE = 0.09 vs. M = 16.24, SE = 0.09; p = 0.03) compared with standard care. Mothers' use of emotion-based food to soothe was lower in the RP intervention compared with standard care from age 2 to 6 months [M difference = -0.32, standard deviation (SD) = 0.81 vs. 0.00, SD = 0.90; p = 0.01]. Conclusions: This pragmatic, patient-centered RP intervention did not reduce rapid infant weight gain or overweight but was associated with modestly lower infant BMI and reduced mothers' use of emotion-based food to soothe. Trial Registration: clinicaltrials.gov identifier: NCT03482908.
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Affiliation(s)
- Jennifer S Savage
- Center for Childhood Obesity Research, The Pennsylvania State University, University Park, PA, USA
| | - Amy M Moore
- Center for Childhood Obesity Research, The Pennsylvania State University, University Park, PA, USA
| | - Samantha M R Kling
- Evaluation Sciences Unit, Division of Primary Care Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Michele Marini
- Center for Childhood Obesity Research, The Pennsylvania State University, University Park, PA, USA
| | - Erika Hernandez
- Center for Childhood Obesity Research, The Pennsylvania State University, University Park, PA, USA
| | | | - Sandra Hassink
- Nemours Children's Health (Emeritus), Wilmington, DE, USA
| | - Ian M Paul
- Pediatrics and Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Lisa Bailey-Davis
- Population Health Sciences, Obesity Institute, Geisinger, Danville, PA, USA
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Gabbard J, Sadarangani TR, Datta R, Fabius CD, Gettel CJ, Douglas NF, Juckett LA, Kiselica AM, Murali KP, McCarthy EP, Torke AM, Callahan CM. Career development in pragmatic clinical trials to improve care for people living with dementia. J Am Geriatr Soc 2023; 71:3554-3565. [PMID: 37736669 PMCID: PMC10810339 DOI: 10.1111/jgs.18599] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 08/16/2023] [Accepted: 08/19/2023] [Indexed: 09/23/2023]
Abstract
The growing number of people living with dementia (PLWD) requires a coordinated clinical response to deliver pragmatic, evidence-based interventions in frontline care settings. However, infrastructure to support such a response is lacking. Moreover, there are too few researchers conducting rigorous embedded pragmatic clinical trials (ePCTs) to make the vision of high quality, widely accessible dementia care a reality. National Institute on Aging (NIA) Imbedded Pragmatic Alzheimer's disease and Related Dementias Clinical Trials (IMPACT) Collaboratory seeks to improve the pipeline of early career researchers qualified to lead ePCTs by funding career development awards. Even with support from the Collaboratory, awardees face practical and methodological challenges to success, recently exacerbated by the COVID-19 pandemic. We first describe the training opportunities and support network for the IMPACT CDA recipients. This report then describes the unique career development challenges faced by early-career researchers involved in ePCTs for dementia care. Topics addressed include challenges in establishing a laboratory, academic promotion, mentoring and professional development, and work-life balance. Concrete suggestions to address these challenges are offered for early-career investigators, their mentors, and their supporting institutions. While some of these challenges are faced by researchers in other fields, this report seeks to provide a roadmap for expanding the work of the IMPACT Collaboratory and initiating future efforts to recruit, train, and retain talented early-career researchers involved in ePCTs for dementia care.
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Affiliation(s)
- Jennifer Gabbard
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | | | - Rupak Datta
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
| | - Chanee D. Fabius
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Cameron J. Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
| | - Natalie F. Douglas
- Department of Communication Sciences and Disorders, The Herbert H. and Grace A. Dow College of Health Professions, Central Michigan University, Mt. Pleasant, Michigan
| | - Lisa A Juckett
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio
| | - Andrew M. Kiselica
- Department of Health Psychology, School of Health Professions, University of Missouri, Columbia, Missouri
| | | | - Ellen P. McCarthy
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alexia M. Torke
- Division of General Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Christopher M. Callahan
- Division of General Medicine and Geriatrics, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana
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George G, Russell B, Rigg A, Coolen ACC, Van Hemelrijck M. Real World Data Studies of Antineoplastic Drugs: How Can They Be Improved to Steer Everyday Use in the Clinic? Pragmat Obs Res 2023; 14:95-100. [PMID: 37701044 PMCID: PMC10493103 DOI: 10.2147/por.s395959] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/28/2023] [Indexed: 09/14/2023] Open
Abstract
There is a growing interest in real world evidence when developing antineoplastic drugs owing to the shorter length of time and low costs compared to randomised controlled trials. External validity of studies in the regulatory phase can be enhanced by complementing randomised controlled trials with real world evidence. Furthermore, the use of real world evidence ensures the inclusion of patients often excluded from randomised controlled trials such as the elderly, certain ethnicities or those from certain geographical areas. This review explores approaches in which real world data may be integrated with randomised controlled trials. One approach is by using big data, especially when investigating drugs in the antineoplastic setting. This can even inform artificial intelligence thus ensuring faster and more precise diagnosis and treatment decisions. Pragmatic trials also offer an approach to examine the effectiveness of novel antineoplastic drugs without evading the benefits of randomised controlled trials. A well-designed pragmatic trial would yield results with high external validity by employing a simple study design with a large sample size and diverse settings. Although randomised controlled trials can determine efficacy of antineoplastic drugs, effectiveness in the real world may differ. The need for pragmatic trials to help guide healthcare decision-making led to the development of trials within cohorts (TWICs). TWICs make use of cohorts to conduct multiple randomised controlled trials while maintaining characteristics of real world data in routine clinical practice. Although real world data is often affected by incomplete data and biases such as selection and unmeasured biases, the use of big data and pragmatic approaches can improve the use of real world data in the development of antineoplastic drugs that can in turn steer decision-making in clinical practice.
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Affiliation(s)
- Gincy George
- Translational Oncology and Urology Research, King’s College London, London, UK
| | - Beth Russell
- Translational Oncology and Urology Research, King’s College London, London, UK
| | - Anne Rigg
- Guy’s Cancer Centre, Guy’s and St Thomas NHS Foundation Trust, London, UK
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Shen R, Mulder H, Wruck L, Weissler EH, Robertson HR, Sharlow AG, Kripalani S, Muñoz D, Effron MB, Gupta K, Girotra S, Whittle J, Benziger CP, VanWormer JJ, Polonsky TS, Rothman RL, Harrington RA, Hernandez AF, Jones WS. Internet Versus Noninternet Participation in a Decentralized Clinical Trial: Lessons From the ADAPTABLE Study. J Am Heart Assoc 2023; 12:e027899. [PMID: 37345815 PMCID: PMC10356087 DOI: 10.1161/jaha.122.027899] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 08/21/2022] [Accepted: 05/23/2023] [Indexed: 06/23/2023]
Abstract
Background Internet-based participation has the potential to enhance pragmatic and decentralized trials, where representative study populations and generalizability to clinical practice are key. We aimed to study the differences between internet and noninternet/telephone participants in a large remote, pragmatic trial. Methods and Results In a subanalysis of the ADAPTABLE (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness) study, we compared internet participants with those who opted for noninternet participation. Study process measures examined included participant characteristics at consent, study medication adherence, and study retention. The clinical outcome examined was a composite of all-cause mortality, hospitalization for myocardial infarction, or hospitalization for stroke. Noninternet participants were older (mean 69.4 versus 67.4 years), more likely to be female (38.9% versus 30.2%), more likely to be Black (27.3% versus 6.0%) or Hispanic (11.1% versus 2.0%), and had a higher number of comorbid conditions. The composite clinical outcome was more than twice as high in noninternet participants. The hazard of nonadherence to the assigned aspirin dosage was 46% higher in noninternet participants than internet participants. Conclusions Noninternet participants differed from internet participants in notable demographic characteristics while having poorer baseline health. Over the course of ADAPTABLE, they also had worse clinical outcomes and greater likelihood of study drug nonadherence. These results suggest that trials focused on internet participation select for younger, healthier participants with a higher proportion of traditionally overrepresented patients. Allowing noninternet participation enhances diversity; however, additional steps may be needed to promote study retention and study medication adherence. Registration Information clinicaltrials.gov. Identifier: NCT02697916.
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Affiliation(s)
| | | | - Lisa Wruck
- Duke Clinical Research InstituteDurhamNCUSA
| | - E. Hope Weissler
- Division of Vascular and Endovascular SurgeryDuke University School of MedicineDurhamNCUSA
| | | | | | | | - Daniel Muñoz
- Vanderbilt University Medical CenterNashvilleTNUSA
| | - Mark B. Effron
- University of Queensland‐Ochsner Clinical SchoolNew OrleansLAUSA
| | - Kamal Gupta
- University of Kansas Medical CenterKansas CityKAUSA
| | | | | | | | | | | | | | | | | | - W. Schuyler Jones
- Duke Clinical Research InstituteDurhamNCUSA
- Division of CardiologyDuke University Health SystemDurhamNCUSA
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Hohenschurz-Schmidt DJ, Cherkin D, Rice AS, Dworkin RH, Turk DC, McDermott MP, Bair MJ, DeBar LL, Edwards RR, Farrar JT, Kerns RD, Markman JD, Rowbotham MC, Sherman KJ, Wasan AD, Cowan P, Desjardins P, Ferguson M, Freeman R, Gewandter JS, Gilron I, Grol-Prokopczyk H, Hertz SH, Iyengar S, Kamp C, Karp BI, Kleykamp BA, Loeser JD, Mackey S, Malamut R, McNicol E, Patel KV, Sandbrink F, Schmader K, Simon L, Steiner DJ, Veasley C, Vollert J. Research objectives and general considerations for pragmatic clinical trials of pain treatments: IMMPACT statement. Pain 2023; 164:1457-1472. [PMID: 36943273 PMCID: PMC10281023 DOI: 10.1097/j.pain.0000000000002888] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 02/10/2022] [Revised: 01/09/2023] [Accepted: 01/12/2023] [Indexed: 03/23/2023]
Abstract
ABSTRACT Many questions regarding the clinical management of people experiencing pain and related health policy decision-making may best be answered by pragmatic controlled trials. To generate clinically relevant and widely applicable findings, such trials aim to reproduce elements of routine clinical care or are embedded within clinical workflows. In contrast with traditional efficacy trials, pragmatic trials are intended to address a broader set of external validity questions critical for stakeholders (clinicians, healthcare leaders, policymakers, insurers, and patients) in considering the adoption and use of evidence-based treatments in daily clinical care. This article summarizes methodological considerations for pragmatic trials, mainly concerning methods of fundamental importance to the internal validity of trials. The relationship between these methods and common pragmatic trials methods and goals is considered, recognizing that the resulting trial designs are highly dependent on the specific research question under investigation. The basis of this statement was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) systematic review of methods and a consensus meeting. The meeting was organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership. The consensus process was informed by expert presentations, panel and consensus discussions, and a preparatory systematic review. In the context of pragmatic trials of pain treatments, we present fundamental considerations for the planning phase of pragmatic trials, including the specification of trial objectives, the selection of adequate designs, and methods to enhance internal validity while maintaining the ability to answer pragmatic research questions.
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Affiliation(s)
- David J. Hohenschurz-Schmidt
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Dan Cherkin
- Department of Family Medicine, University of Washington and Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Andrew S.C. Rice
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Robert H. Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C. Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Michael P. McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States
| | - Matthew J. Bair
- VA Center for Health Information and Communication, Regenstrief Institute, and Indiana University School of Medicine, Indianapolis, IN, United States
| | - Lynn L. DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | | | - John T. Farrar
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology and Psychology, Yale University, New Haven, CT, United States
| | - John D. Markman
- Neuromedicine Pain Management and Translational Pain Research, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Michael C. Rowbotham
- Department of Anesthesia, University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Karen J. Sherman
- Kaiser Permanente Washington Health Research Institute and Department of Epidemiology, University of Washington, Seattle WA, United States
| | - Ajay D. Wasan
- Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | - Paul Desjardins
- Department of Diagnostic Sciences, School of Dental Medicine, Rutgers University, Newark, NJ, United States
| | - McKenzie Ferguson
- Department of Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, IL, United States
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - Jennifer S. Gewandter
- Department of Anesthesiology and Perioperative, University of Rochester, Rochester, NY, United States
| | - Ian Gilron
- Departments of Anesthesiology & Perioperative Medicine, Biomedical & Molecular Sciences, Centre for Neuroscience Studies, and School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - Hanna Grol-Prokopczyk
- Department of Sociology, University at Buffalo, State University of New York, Buffalo NY, United States
| | - Sharon H. Hertz
- Hertz and Fields Consulting, Inc, Silver Spring, MD, United States
| | | | - Cornelia Kamp
- Center for Health and Technology (CHeT), Clinical Materials Services Unit (CMSU), University of Rochester Medical Center, Rochester, NY, United States
| | | | - Bethea A. Kleykamp
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - John D. Loeser
- Departments of Neurological Surgery and Anesthesia and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Sean Mackey
- Department of Anesthesiology, Perioperative, and Pain Medicine, Neurosciences and Neurology, Stanford University School of Medicine, Palo Alto, CA, United States
| | | | - Ewan McNicol
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Boston, MA, United States
| | - Kushang V. Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Friedhelm Sandbrink
- Department of Neurology, Washington DC Veterans Affairs Medical Center, Washington, DC, United States
- Department of Neurology, George Washington University, Washington, DC, United States
| | - Kenneth Schmader
- Department of Medicine-Geriatrics, Center for the Study of Aging, Duke University Medical Center, and Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, NC, United States
| | - Lee Simon
- SDG, LLC, Cambridge, MA, United States
| | | | - Christin Veasley
- Chronic Pain Research Alliance, North Kingstown, RI, United States
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Campus Kiel, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
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Hope Weissler E, Stebbins A, Wruck L, Muñoz D, Gupta K, Girotra S, Whittle J, Benziger CP, Polonsky TS, Bradley SM, Hammill BG, Merritt JG, Zemon DN, Hernandez AF, Schuyler Jones W. Outcomes among patients with peripheral artery disease in the Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness (ADAPTABLE) study. Vasc Med 2023; 28:122-130. [PMID: 37025023 PMCID: PMC10795754 DOI: 10.1177/1358863x231154951] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
BACKGROUND We aimed to understand the effects of aspirin dose on outcomes in patients with peripheral artery disease (PAD) as well as their participation in a pragmatic randomized controlled trial. METHODS In a subanalysis of the Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness (ADAPTABLE) study, we compared aspirin doses (81 vs 325 mg) among participants with PAD and study participation metrics in patients with and without PAD. The primary outcome composite was all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke. RESULTS Among 14,662 participants enrolled in ADAPTABLE with PAD status available, 3493 (23.8%) had PAD. Participants with PAD were more likely to experience the primary composite (13.76% vs 5.31%, p < 0.001), all-cause mortality (7.55% vs 3.01%, p < 0.001), myocardial infarction (5.71% vs 2.09%, p < 0.001), stroke (2.45% vs 0.86%, p < 0.001), and major bleeding (1.19% vs 0.44%, p < 0.001). A higher aspirin dose did not reduce the primary outcome in patients with PAD (13.68% vs 13.84% in 81 mg and 325 mg groups; OR 1.05, 95% CI 0.88-1.25). Participants with PAD were less likely to enroll via email (33.0% vs 41.9%, p < 0.0001), less likely to choose internet follow-up (79.2% vs 89.5%, p < 0.0001), and were more likely to change their aspirin doses (39.7% vs 30.7%, p < 0.0001). CONCLUSIONS ADAPTABLE participants with PAD did not benefit from a higher dose of aspirin and participated in the study differently from those without PAD. These results reinforce the need for additional PAD-specific research and suggest that different trial strategies may be needed for optimal engagement of patients with PAD. (ClinicalTrials.gov Identifier: NCT02697916).
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Affiliation(s)
| | | | - Lisa Wruck
- Duke Clinical Research Institute, Durham, NC
| | - Daniel Muñoz
- Vanderbilt University Medical Center, Nashville, TN
| | - Kamal Gupta
- University of Kansas Medical Center, Kansas City, KS
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Marquis-Gravel G, Faulkner M, Merritt G, Farrehi P, Zemon N, Robertson HR, Jones WS, Kraschnewski J. Importance of patient engagement in the conduct of pragmatic multicenter randomized controlled trials: The ADAPTABLE experience. Clin Trials 2023; 20:31-35. [PMID: 35999816 DOI: 10.1177/17407745221118559] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIMS Actively engaging patient partners in the conduct of trials is crucial to ensure the studies answer genuine, patient-centered, unmet clinical needs, and to facilitate participant recruitment and retention. The aim of this article is to demonstrate the feasibility of patient engagement within a large pragmatic multicenter randomized controlled trial, specifically for the purposes of dissemination of study information/updates and to favorize recruitment and retention. METHODS In the patient-centric, pragmatic ADAPTABLE randomized trial, transparent and timely dissemination of information on the study updates to the trial participants was undertaken to create meaningful engagement and to facilitate retention. A national panel of patient partners, the Adaptors, were directly involved in this information dissemination strategy, and study participants were engaged both nationally and locally to design recruitment methods iteratively during the conduct of the trial. All Adaptors had a lived experience with cardiovascular disease. RESULTS Adaptors attended bi-weekly meetings facilitated by the director of the study's patient-powered research network. They drafted and/or edited newsletters and ad hoc educational information written in a lay-friendly manner for study participants, which were regularly distributed to the ADAPTABLE community, in addition to online forums where participants could share their experience of their involvement in ADAPTABLE. To spur recruitment, a patient-driven initiative was to draft letters sharing their story, which were distributed by the local study teams. Patient partners thought that using patients' voice to provide their perspectives on why they believed this project was important would be more engaging for prospective participants than traditional approaches. CONCLUSIONS ADAPTABLE's experience has demonstrated the feasibility of engaging patients as partners in the conduct of a large-scale, multi-center, pragmatic randomized controlled trial. Future trials should embrace and iteratively improve this model by engaging patient partners as early as study protocol development and funding applications, and quantify its impact on the effectiveness and value of the trial.
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Affiliation(s)
| | - Madelaine Faulkner
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | | | - Peter Farrehi
- University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | - W Schuyler Jones
- Duke Clinical Research Institute, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA
| | - Jennifer Kraschnewski
- Departments of Medicine and Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
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9
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Juckett LA, Oliver HV, Hariharan G, Bunck LE, Devier AL. Strategies for implementing the interRAI home care frailty scale with home-delivered meal clients. Front Public Health 2023; 11:1022735. [PMID: 36755903 PMCID: PMC9900681 DOI: 10.3389/fpubh.2023.1022735] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 01/05/2023] [Indexed: 01/24/2023] Open
Abstract
Introduction Frailty is a complex condition that is highly associated with health decline and the loss of independence. Home-delivered meal programs are designed to provide older adults with health and nutritional support that can attenuate the risk of frailty. However, home-delivered meal agencies do not routinely assess frailty using standardized instruments, leading to uncertainty over the longitudinal impact of home-delivered meals on frailty levels. Considering this knowledge gap, this study aimed to facilitate home-delivered meal staff's implementation of a standardized frailty instrument with meal clients as part of routine programming. This article (a) describes the use of Implementation Mapping principles to develop strategies supporting frailty instrument implementation in one home-delivered meal agency and (b) examines the degree to which a combination of strategies influenced the feasibility of frailty instrument use by home-delivered meal staff at multiple time points. Methods and materials This retrospective observational study evaluated staff's implementation of the interRAI Home Care Frailty Scale (HCFS) with newly enrolled home-delivered meal clients at baseline-, 3-months, and 6-months. The process of implementing the HCFS was supported by five implementation strategies that were developed based on tenets of Implementation Mapping. Rates of implementation and reasons clients were lost to 3- and 6-month follow-up were evaluated using univariate analyses. Client-level data were also examined to identify demographic factors associated with attrition at both follow-up time points. Results Staff implemented the HCFS with 94.8% (n = 561) of eligible home-delivered meal clients at baseline. Of those clients with baseline HCFS data, staff implemented the follow-up HCFS with 43% of clients (n = 241) at 3-months and 18.0% of clients (n = 101) at 6-months. Insufficient client tracking and documentation procedures complicated staff's ability to complete the HCFS at follow-up time points. Discussion While the HCFS assesses important frailty domains that are relevant to home-delivered meal clients, its longitudinal implementation was complicated by several agency- and client-level factors that limited the extent to which the HCFS could be feasibly implemented over multiple time points. Future empirical studies are needed to design and test theoretically derived implementation strategies to support frailty instrument use in the home- and community-based service setting.
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Affiliation(s)
- Lisa A. Juckett
- Occupational Therapy Division, School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, OH, United States,*Correspondence: Lisa A. Juckett ✉
| | - Haley V. Oliver
- Occupational Therapy Division, School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Govind Hariharan
- Coles College of Business, Kennesaw State University, Kennesaw, GA, United States
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10
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Nicholls SG, Al‐Jaishi AA, Niznick H, Carroll K, Madani MT, Peak KD, Madani L, Nevins P, Adisso L, Li F, Weijer C, Mitchell SL, Welch V, Quiñones AR, Taljaard M. Health equity considerations in pragmatic trials in Alzheimer's and dementia disease: Results from a methodological review. Alzheimers Dement (Amst) 2023; 15:e12392. [PMID: 36777091 PMCID: PMC9899766 DOI: 10.1002/dad2.12392] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/20/2022] [Accepted: 12/06/2022] [Indexed: 02/07/2023]
Abstract
Introduction To improve dementia care delivery for persons across all backgrounds, it is imperative that health equity is integrated into pragmatic trials. Methods We reviewed 62 pragmatic trials of people with dementia published 2014 to 2019. We assessed health equity in the objectives; design, conduct, analysis; and reporting using PROGRESS-Plus which stands for Place of residence, Race/ethnicity, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social capital, and other factors such as age and disability. Results Two (3.2%) trials incorporated equity considerations into their objectives; nine (14.5%) engaged with communities; 4 (6.5%) described steps to increase enrollment from equity-relevant groups. Almost all trials (59, 95.2%) assessed baseline balance for at least one PROGRESS-Plus characteristic, but only 10 (16.1%) presented subgroup analyses across such characteristics. Differential recruitment, attrition, implementation, adherence, and applicability across PROGRESS-Plus were seldom discussed. Discussion Ongoing and future pragmatic trials should more rigorously integrate equity considerations in their design, conduct, and reporting. Highlights Few pragmatic trials are explicitly designed to inform equity-relevant objectives.Few pragmatic trials take steps to increase enrollment from equity-relevant groups.Disaggregated results across equity-relevant groups are seldom reported.Adherence to existing tools (e.g., IMPACT Best Practices, CONSORT-Equity) is key.
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Affiliation(s)
- Stuart G. Nicholls
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Ahmed A. Al‐Jaishi
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Harrison Niznick
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Kelly Carroll
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | | | - Katherine D. Peak
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Leen Madani
- Bruyère Research Institute and, University of OttawaOttawaOntarioCanada
| | - Pascale Nevins
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Lionel Adisso
- VITAM – Centre de recherche en santé durableDepartment of Social and Preventive MedicineFaculty of MedicineUniversité LavalQuebecCanada
| | - Fan Li
- Department of BiostatisticsYale University School of Public HealthNew HavenConnecticutUSA
| | - Charles Weijer
- Departments of MedicineEpidemiology & Biostatistics, and PhilosophyWestern UniversityLondonOntarioCanada
| | - Susan L. Mitchell
- Hebrew SeniorLife, Marcus Institute for Aging ResearchBostonMassachusettsUSA
| | - Vivian Welch
- Bruyère Research Institute andSchool of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada
| | - Ana R. Quiñones
- Department of Family MedicineOregon Health & Science UniversityPortlandOregonUSA
| | - Monica Taljaard
- Clinical Epidemiology ProgramOttawa Hospital Research Institute andSchool of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada
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11
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Hossain MB, Karim ME. Key considerations for choosing a statistical method to deal with incomplete treatment adherence in pragmatic trials. Pharm Stat 2023; 22:205-231. [PMID: 36637242 DOI: 10.1002/pst.2258] [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: 08/13/2021] [Revised: 05/27/2022] [Accepted: 07/15/2022] [Indexed: 02/01/2023]
Abstract
Pragmatic trials offer practical means of obtaining real-world evidence to help improve decision-making in comparative effectiveness settings. Unfortunately, incomplete adherence is a common problem in pragmatic trials. The commonly used methods in randomized control trials often cannot handle the added complexity imposed by incomplete adherence, resulting in biased estimates. Several naive methods and advanced causal inference methods (e.g., inverse probability weighting and instrumental variable-based approaches) have been used in the literature to deal with incomplete adherence. Practitioners and applied researchers are often confused about which method to consider under a given setting. This current work is aimed to review commonly used statistical methods to deal with non-adherence along with their key assumptions, advantages, and limitations, with a particular focus on pragmatic trials. We have listed the applicable settings for these methods and provided a summary of available software. All methods were applied to two hypothetical datasets to demonstrate how these methods perform in a given scenario, along with the R codes. The key considerations include the type of intervention strategy (point treatment settings, where treatment is administered only once versus sustained treatment settings, where treatment has to be continued over time) and availability of data (e.g., the extent of measured or unmeasured covariates that are associated with adherence, dependent confounding impacted by past treatment, and potential violation of assumptions). This study will guide practitioners and applied researchers to use the appropriate statistical method to address incomplete adherence in pragmatic trial settings for both the point and sustained treatment strategies.
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Affiliation(s)
- Md Belal Hossain
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, University of British Columbia, Vancouver, Canada.,Centre for Health Evaluation and Outcome Sciences, University of British Columbia, Vancouver, Canada
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12
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Tallarico RT, Neto AS, Legrand M. Pragmatic platform trials to improve the outcome of patients with acute kidney injury. Curr Opin Crit Care 2022; 28:622-629. [PMID: 36170383 PMCID: PMC9613599 DOI: 10.1097/mcc.0000000000000990] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW There is an important need for improved diagnostic strategies and treatment among patients with acute kidney injury (AKI). Classical randomized clinical trials have generated relevant results in AKI but are associated with shortcomings, such as high costs and sometimes lack of generalizability. In this minireview, we discuss the value and limits of pragmatic trials and platform trials for AKI research. RECENT FINDINGS The implementation of pragmatic and platform trials in critical care settings has generated relevant clinical evidence impacting clinical practice. Pragmatic and platform designs have recently been applied to patients at risk of AKI and represent a crucial opportunity to advance our understanding of optimized treatment and strategies in patients at risk of AKI or presenting with AKI. Trials embedded in electronic health records can facilitate patient enrollment and data collection. Platform trials have allowed for a more efficient study design. Although both pragmatic and platform trials have several advantages, they also come with the challenges and shortcomings discussed in this review. SUMMARY Pragmatic and platform trials can provide clinical answers in 'real-life' settings, facilitate a significant sample size enrollment at a limited cost, and provide results that can have a faster implementation in clinical practice.
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Affiliation(s)
- Roberta T Tallarico
- Division of Critical Care Medicine, Department of Anesthesia & Perioperative Care, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Ary S Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University
- Department of Intensive Care, Austin Hospital
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Matthieu Legrand
- Division of Critical Care Medicine, Department of Anesthesia & Perioperative Care, University of California, San Francisco (UCSF), San Francisco, California, USA
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13
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Dore DD, Myles L, Recker A, Burns D, Rogers Murray C, Gifford D, Mor V. The Long-Term Care Data Cooperative: The Next Generation of Data Integration. J Am Med Dir Assoc 2022; 23:2031-2033. [PMID: 36209889 PMCID: PMC9742312 DOI: 10.1016/j.jamda.2022.09.006] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/12/2022] [Accepted: 09/11/2022] [Indexed: 11/06/2022]
Abstract
Despite important advances in the linkage of residents' Medicare claims and Minimum Data Set (MDS) information, the data infrastructure for long-term care remains inadequate for public health surveillance and clinical research. It is widely known that the evidence base supporting treatment decisions for older nursing home residents is scant as residents are systematically excluded from clinical trials. Electronic health records (EHRs) hold the promise to improve this population's representation in clinical research, especially with the more timely and detailed clinical information available in EHRs that are lacking in claims and MDS. The COVID-19 pandemic shined a spotlight on the data gap in nursing homes. To address this need, the National Institute on Aging funded the Long-Term Care (LTC) Data Cooperative, a collaboration among providers and stakeholders in academia, government, and the private sector. The LTC Data Cooperative assembles residents' EHRs from major specialty vendors and facilitates linkage of these data with Medicare claims to create a comprehensive, longitudinal patient record. These data serve 4 key purposes: (1) health care operations and population health analytics; (2) public health surveillance; (3) observational, comparative effectiveness research; and (4) clinical research studies, including provider and patient recruitment into Phase 3 and Phase 4 randomized trials. Federally funded researchers wanting to conduct pragmatic trials can now enroll their partnering sites in this Cooperative to more easily access the clinical data needed to close the evidence gaps in LTC. Linkage to Medicare data facilitates tracking patients' long-term outcomes after being discharged back to the community. As of August 2022, nearly 1000 nursing homes have joined, feedback reports to facilities are being piloted, algorithms for identifying infections are being tested, and proposals for use of the data have been reviewed and approved. This emerging EHR system is a substantial innovation in the richness and timeliness of the data infrastructure of the nursing home population.
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Affiliation(s)
- David D. Dore
- Exponent Inc, Menlo Park, CA, USA,Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI, USA
| | - Lonnita Myles
- Research Department, American Health Care Association and the National Center for Assisted Living, Washington, DC, USA
| | - Amy Recker
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI, USA
| | | | - Catherine Rogers Murray
- Exponent Inc, Menlo Park, CA, USA,Address correspondence to Catherine Rogers Murray, MPH, Exponent Inc, 1075 Worcester Street, Natick, MA 01760, USA., (C. Rogers Murray)
| | - David Gifford
- Research Department, American Health Care Association and the National Center for Assisted Living, Washington, DC, USA,Center of Health Policy and Evaluation in Long-Term Care, American Health Care Association, Washington, DC, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI, USA,Veterans Administration Medical Center, Providence, RI, USA
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14
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Ganz DA, Yuan AH, Greene EJ, Latham NK, Araujo K, Siu AL, Magaziner J, Gurwitz JH, Wu AW, Alexander NB, Wallace RB, Greenspan SL, Rich J, Volpi E, Waring SC, Dykes PC, Ko F, Resnick NM, McMahon SK, Basaria S, Wang R, Lu C, Esserman D, Dziura J, Miller ME, Travison TG, Peduzzi P, Bhasin S, Reuben DB, Gill TM. Effect of the STRIDE fall injury prevention intervention on falls, fall injuries, and health-related quality of life. J Am Geriatr Soc 2022; 70:3221-3229. [PMID: 35932279 PMCID: PMC9669115 DOI: 10.1111/jgs.17964] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 05/14/2022] [Revised: 05/29/2022] [Accepted: 06/05/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Falls are common in older adults and can lead to severe injuries. The Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) trial cluster-randomized 86 primary care practices across 10 health systems to a multifactorial intervention to prevent fall injuries, delivered by registered nurses trained as falls care managers, or enhanced usual care. STRIDE enrolled 5451 community-dwelling older adults age ≥70 at increased fall injury risk. METHODS We assessed fall-related outcomes via telephone interviews of participants (or proxies) every 4 months. At baseline, 12 and 24 months, we assessed health-related quality of life (HRQOL) using the EQ-5D-5L and EQ-VAS. We used Poisson models to assess intervention effects on falls, fall-related fractures, fall injuries leading to hospital admission, and fall injuries leading to medical attention. We used hierarchical longitudinal linear models to assess HRQOL. RESULTS For recurrent event models, intervention versus control incidence rate ratios were 0.97 (95% confidence interval [CI], 0.93-1.00; p = 0.048) for falls, 0.93 (95% CI, 0.80-1.08; p = 0.337) for self-reported fractures, 0.89 (95% CI, 0.73-1.07; p = 0.205) for adjudicated fractures, 0.91 (95% CI, 0.77-1.07; p = 0.263) for falls leading to hospital admission, and 0.97 (95% CI, 0.89-1.06; p = 0.477) for falls leading to medical attention. Similar effect sizes (non-significant) were obtained for dichotomous outcomes (e.g., participants with ≥1 events). The difference in least square mean change over time in EQ-5D-5L (intervention minus control) was 0.009 (95% CI, -0.002 to 0.019; p = 0.106) at 12 months and 0.005 (95% CI, -0.006 to 0.015; p = 0.384) at 24 months. CONCLUSIONS Across a standard set of outcomes typically reported in fall prevention studies, we observed modest improvements, one of which was statistically significant. Future work should focus on patient-, practice-, and organization-level operational strategies to increase the real-world effectiveness of interventions, and improving the ability to detect small but potentially meaningful clinical effects. CLINICALTRIALS gov identifier: NCT02475850.
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Affiliation(s)
- David A. Ganz
- Department of Medicine, David Geffen School of Medicine at UCLA; Los Angeles, CA
- Geriatric Research, Education and Clinical Center; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Anita H. Yuan
- Department of Medicine, David Geffen School of Medicine at UCLA; Los Angeles, CA
| | - Erich J. Greene
- Yale Center for Analytical Sciences, Department of Biostatistics; Yale School of Public Health; New Haven, CT
| | - Nancy K. Latham
- Boston Claude D. Pepper Older Americans Independence Center; Research Program in Men’s Health: Aging and Metabolism; Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Katy Araujo
- Yale Claude D. Pepper Older Americans Independence Center; Yale University; New Haven, CT
| | - Albert L. Siu
- Icahn School of Medicine at Mount Sinai, New York, NY
- Geriatric Research, Education and Clinical Center, James J. Peters VA Healthcare System, Bronx, NY
| | - Jay Magaziner
- University of Maryland School of Medicine, Baltimore, MD
| | - Jerry H. Gurwitz
- Meyers Health Care Institute, a joint endeavor of Reliant Medical Group, Fallon Health, and UMass Chan Medical School, Worcester, MA
| | - Albert W. Wu
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Neil B. Alexander
- University of Michigan; Geriatric Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - Susan L. Greenspan
- Pittsburgh Claude D. Pepper Older Americans Independence Center, Division of Geriatrics and Gerontology, University of Pittsburgh, Pittsburgh PA
| | - Jeremy Rich
- HealthCare Partners Institute for Applied Research and Education, El Segundo, CA
| | - Elena Volpi
- University of Texas Medical Branch Claude D. Pepper Older Americans Independence Center; Sealy Center on Aging, The University of Texas Medical Branch, Galveston, TX
| | | | | | - Fred Ko
- Icahn School of Medicine at Mount Sinai, New York, NY
- Geriatric Research, Education and Clinical Center, James J. Peters VA Healthcare System, Bronx, NY
| | - Neil M. Resnick
- Pittsburgh Claude D. Pepper Older Americans Independence Center, Division of Geriatrics and Gerontology, University of Pittsburgh, Pittsburgh PA
| | | | - Shehzad Basaria
- Boston Claude D. Pepper Older Americans Independence Center; Research Program in Men’s Health: Aging and Metabolism; Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Rixin Wang
- Yale Center for Medical Informatics, New Haven, CT
| | - Charles Lu
- Yale Center for Medical Informatics, New Haven, CT
| | - Denise Esserman
- Yale Center for Analytical Sciences, Department of Biostatistics; Yale School of Public Health; New Haven, CT
| | - James Dziura
- Yale Center for Analytical Sciences, Department of Biostatistics; Yale School of Public Health; New Haven, CT
| | | | - Thomas G. Travison
- Boston Claude D. Pepper Older Americans Independence Center; Research Program in Men’s Health: Aging and Metabolism; Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, MA
| | - Peter Peduzzi
- Yale Center for Analytical Sciences, Department of Biostatistics; Yale School of Public Health; New Haven, CT
| | - Shalender Bhasin
- Boston Claude D. Pepper Older Americans Independence Center; Research Program in Men’s Health: Aging and Metabolism; Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - David B. Reuben
- Department of Medicine, David Geffen School of Medicine at UCLA; Los Angeles, CA
| | - Thomas M. Gill
- Yale Claude D. Pepper Older Americans Independence Center; Yale University; New Haven, CT
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15
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Berman AN, Wasfy JH. Translating Clinical Guidelines Into Care Delivery Innovation: The Importance of Rigorous Methods for Generating Evidence. J Am Heart Assoc 2022; 11:e026677. [PMID: 35766287 PMCID: PMC9333392 DOI: 10.1161/jaha.122.026677] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Adam N Berman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital Harvard Medical School Boston MA
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital Harvard Medical School Boston MA
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16
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Marino M, Heintzman J. Randomized Trials in Primary Care: Becoming Pragmatic. Ann Fam Med 2022; 20:201-202. [PMID: 35606131 PMCID: PMC9199046 DOI: 10.1370/afm.2832] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 04/08/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon
| | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.,OCHIN Inc, Portland, Oregon
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17
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Levy C, Zimmerman S, Mor V, Gifford D, Greenberg SA, Klinger JH, Lieblich C, Linnebur S, McAllister A, Nazir A, Pace D, Stone R, Resnick B, Sloane PD, Ouslander J, Gaugler JE. Pragmatic Trials in Long-Term Care: Implementation and Dissemination Challenges and Opportunities. J Am Geriatr Soc 2022; 70:709-717. [PMID: 35195281 PMCID: PMC8944211 DOI: 10.1111/jgs.17698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 11/28/2022]
Abstract
Randomized controlled trials are considered the most rigorous research design in efficacy and effectiveness research; however, such trials present numerous challenges that limit their applicability in real-world settings. As a consequence, pragmatic trials are increasingly viewed as a research design that overcomes some of these barriers with the potential to produce findings that are more reproducible. Although pragmatic methodology in long-term care is receiving increasing attention as an approach to improve successful dissemination and implementation, pragmatic trials present complexities of their own. To address these complexities and related issues, experts with experience conducting pragmatic trials, developing nursing home policy, participating in advocacy efforts, and providing clinical care in long-term care settings participated in a virtual consensus conference funded by the National Institute on Aging in Spring 2021. Participants identified 4 cross-cutting principles key to dissemination and implementation of pragmatic trial interventions: (1) stakeholder engagement, (2) diversity and inclusion, (3) organizational strain and readiness, and (4) learn from adaptations. Participants emphasized that implementation processes must be grounded in the perspectives of the people who will ultimately be responsible for implementing the intervention once it is proven to be effective. In addition, messaging must speak to long-term care staff and all others who have a stake in its outcomes. Although our understanding of dissemination and implementation strategies remains underdeveloped, this article is designed to guide long-term care researchers and community providers who are increasingly aware of the need for pragmatism in disseminating and implementing evidence-based care interventions.
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Affiliation(s)
- Cari Levy
- Department of Veterans Affairs, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA,University of Colorado, Aurora, CO, USA,Address correspondence to Cari Levy, MD, PhD, Division of Health Care Policy and Research, University of Colorado at Denver HSC, 13611 E Colfax Ave, Aurora, CO 80045, USA. (C. Levy)
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vincent Mor
- Center of Innovation in Long-term Services and Supports, Providence VA Medical Center, Providence, RI, USA,Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - David Gifford
- Center for Health Policy Evaluation, American Health Care Association, Washington, DC, USA,Center for Quality and Innovation, School of Public Health, Brown University, Providence, RI, USA
| | | | | | | | | | | | - Arif Nazir
- Signature HealthCARE, Louisville, KY, USA
| | | | | | - Barbara Resnick
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Philip D. Sloane
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joseph Ouslander
- Department of Integrated Medical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Joseph E. Gaugler
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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18
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Resnick B, Zimmerman S, Gaugler J, Ouslander J, Abrahamson K, Brandt N, Colón-Emeric C, Galik E, Gravenstein S, Mody L, Sloane PD, Unroe K, Verbeek H. Pragmatic Trials in Long-Term Care: Research Challenges and Potential Solutions in Relation to Key Areas of Care. J Am Geriatr Soc 2022; 70:718-730. [PMID: 35195283 PMCID: PMC8904288 DOI: 10.1111/jgs.17699] [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: 02/01/2022] [Accepted: 02/01/2022] [Indexed: 12/01/2022]
Abstract
As a method of research, pragmatic trials are recommended so as to generate results that are applicable to real-world care. This intent is especially important for the millions of older adults who receive long-term care in thousands of nursing homes and assisted living communities across the country-and many millions more around the globe. This article presents key points raised by experts participating in a conference funded by the National Institute of Aging held at the 2021 conference of the Society for Post-Acute and Long-term Care Medicine. The purpose of the conference was to convene leading clinicians, researchers, and industry partners to address special considerations of pragmatic trials in long-term care. Cross-cutting and unique challenges and solutions to conducting pragmatic trials were discussed focusing on 3 areas of clinical relevance to long-term care: (1) functional care and outcomes, (2) psychosocial care and quality of life, and (3) medical care and outcomes, with a special focus on persons with dementia. Challenges and innovative solutions were organized across the 9 domains of the revised Pragmatic-Explanatory Continuum Indicator Summary (PRECIS) Tool, and future research recommendations for pragmatic trials in long-term care were identified.
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Affiliation(s)
- Barbara Resnick
- University of Maryland School of Nursing, Baltimore, MD, USA,Address correspondence to Barbara Resnick, PhD, CRNP, University of Maryland School of Nursing, 655 W Lombard St, Baltimore, MD 21201, USA. (B. Resnick)
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Pubic Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joseph Gaugler
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Joseph Ouslander
- Department of Integrated Medical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | | | - Nicole Brandt
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | | | - Elizabeth Galik
- University of Maryland School of Nursing, Baltimore, MD, USA
| | - Stefan Gravenstein
- Brown University and Providence Veterans Administration Medical Center, Providence, RI, USA
| | - Lona Mody
- University of Michigan and Veterans Affair, Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Philip D. Sloane
- Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Pubic Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kathleen Unroe
- Indiana University School of Medicine and Regenstrief Institute, Inc, Center for Aging Research, Indianapolis, IN, USA
| | - Hilde Verbeek
- Maastricht University and Living Lab in Ageing and Long-Term Care, Maastricht, the Netherlands
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19
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Fiscella K, He H, Sanders M, Cassells A, Carroll JK, Williams SK, Cornell J, Holder T, Khalida C, Tobin JN. Blood Pressure Visit Intensification in Treatment (BP-Visit) Findings: a Pragmatic Stepped Wedge Cluster Randomized Trial. J Gen Intern Med 2022; 37:32-9. [PMID: 34379277 DOI: 10.1007/s11606-021-07016-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 06/29/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Shortening time between office visits for patients with uncontrolled hypertension represents a potential strategy for improving blood pressure (BP). OBJECTIVE We evaluated the impact of multimodal strategies on time between visits and on improvement in systolic BP (SBP) among patients with uncontrolled hypertension. DESIGN We used a stepped-wedge cluster randomized controlled trial with three wedges involving 12 federally qualified health centers with three study periods: pre-intervention, intervention, and post-intervention. PARTICIPANTS Adult patients with diagnosed hypertension and two BPs ≥ 140/90 pre-randomization and at least one visit during post-randomization control period (N = 4277). INTERVENTION The core intervention included three, clinician hypertension group-based trainings, monthly clinician feedback reports, and monthly meetings with practice champions to facilitate implementation. MAIN MEASURES The main measures were change in time between visits when BP was not controlled and change in SBP. A secondary planned outcome was changed in BP control among all hypertension patients in the practices. KEY RESULTS Median follow-up times were 34, 32, and 32 days and the mean SBPs were 142.0, 139.5, and 139.8 mmHg, respectively. In adjusted analyses, the intervention did not improve time to the next visit compared with control periods, HR = 1.01 (95% CI: 0.98, 1.04). SBP was reduced by 1.13 mmHg (95% CI: -2.10, -0.16), but was not maintained during follow-up. Hypertension control (< 140/90) in the practices improved by 5% during intervention (95% CI: 2.6%, 7.3%) and was sustained post-intervention 5.4% (95% CI: 2.6%, 8.2%). CONCLUSIONS The intervention failed to shorten follow-up time for patients with uncontrolled BP and showed very small, statistically significant improvements in SBP that were not sustained. However, the intervention showed statistically and clinically relevant improvement in hypertension control suggesting that the intervention affected clinician decision-making regarding BP control apart from visit frequency. Future practice initiatives should consider hypertension control as a primary outcome. CLINICAL TRIAL www.ClinicalTrials.gov Identifier: NCT02164331.
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20
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Hohenschurz-Schmidt D, Kleykamp BA, Draper-Rodi J, Vollert J, Chan J, Ferguson M, McNicol E, Phalip J, Evans SR, Turk DC, Dworkin RH, Rice AS. Pragmatic trials of pain therapies: a systematic review of methods. Pain 2022; 163:21-46. [PMID: 34490854 PMCID: PMC8675058 DOI: 10.1097/j.pain.0000000000002317] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 12/05/2022]
Abstract
ABSTRACT Pragmatic randomised clinical trials aim to directly inform clinical or health policy decision making. Here, we systematically review methods and design of pragmatic trials of pain therapies to examine methods, identify common challenges, and areas for improvement. Seven databases were searched for pragmatic randomised controlled clinical trials that assessed pain treatment in a clinical population of adults reporting pain. All screening steps and data extractions were performed twice. Data were synthesised descriptively, and correlation analyses between prespecified trial features and PRECIS-2 (PRagmatic-Explanatory Continuum Indicator Summary 2) ratings and attrition were performed. Protocol registration: PROSPERO-ID CRD42020178954. Of 57 included trials, only 21% assessed pharmacological interventions, the remainder physical, surgical, psychological, or self-management pain therapies. Three-quarters of the trials were comparative effectiveness designs, often conducted in multiple centres (median: 5; Q1/3: 1, 9.25) and with a median sample size of 234 patients at randomization (Q1/3: 135.5; 363.5). Although most trials recruited patients with chronic pain, reporting of pain duration was poor and not well described. Reporting was comprehensive for most general items, while often deficient for specific pragmatic aspects. Average ratings for pragmatism were highest for treatment adherence flexibility and clinical relevance of outcome measures. They were lowest for patient recruitment methods and extent of follow-up measurements and appointments. Current practice in pragmatic trials of pain treatments can be improved in areas such as patient recruitment and reporting of methods, analysis, and interpretation of data. These improvements will facilitate translatability to other real-world settings-the purpose of pragmatic trials.
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Affiliation(s)
| | - Bethea A. Kleykamp
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Jerry Draper-Rodi
- Research Center, University College of Osteopathy, London, United Kingdom
| | - Jan Vollert
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, United Kingdom
| | - Jessica Chan
- Faculty of Medicine, Imperial College, London, United Kingdom
| | - McKenzie Ferguson
- Department of Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, IL, United States
| | - Ewan McNicol
- Department of Pharmacy Practice, MCPHS University, Boston, MA, United States
| | - Jules Phalip
- European School of Osteopathy, Maidstone, United Kingdom
| | - Scott R. Evans
- Department of Biostatistics and Bioinformatics, Biostatistics Center, Milken Institute School of Public Health, George Washington University, Washington, DC, United States
| | - Dennis C. Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Robert H. Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Andrew S.C. Rice
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, United Kingdom
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21
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Carhart-Harris RL, Wagner AC, Agrawal M, Kettner H, Rosenbaum JF, Gazzaley A, Nutt DJ, Erritzoe D. Can pragmatic research, real-world data and digital technologies aid the development of psychedelic medicine? J Psychopharmacol 2022; 36:6-11. [PMID: 33888025 PMCID: PMC8801625 DOI: 10.1177/02698811211008567] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Favourable regulatory assessments, liberal policy changes, new research centres and substantial commercial investment signal that psychedelic therapy is making a major comeback. Positive findings from modern trials are catalysing developments, but it is questionable whether current confirmatory trials are sufficient for advancing our understanding of safety and best practice. Here we suggest supplementing traditional confirmatory trials with pragmatic trials, real-world data initiatives and digital health solutions to better support the discovery of optimal and personalised treatment protocols and parameters. These recommendations are intended to help support the development of safe, effective and cost-efficient psychedelic therapy, which, given its history, is vulnerable to excesses of hype and regulation.
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Affiliation(s)
- Robin L Carhart-Harris
- Centre for Psychedelic Research, Imperial College London, London, UK,Robin L Carhart-Harris, Centre for Psychedelic Research, Imperial College London, Burlington Danes Building, London W12 0NN, UK.
| | - Anne C Wagner
- Remedy, Toronto, Canada,Department of Psychology, Ryerson University, Toronto, Canada
| | - Manish Agrawal
- Maryland Oncology and Hematology, Rockville, USA,Aquilino Cancer Center, Rockville, USA
| | - Hannes Kettner
- Centre for Psychedelic Research, Imperial College London, London, UK
| | | | - Adam Gazzaley
- Neuroscape, Department of Neurology, Physiology and Psychiatry, University of California San Francisco, San Francisco, USA
| | - David J Nutt
- Centre for Psychedelic Research, Imperial College London, London, UK
| | - David Erritzoe
- Centre for Psychedelic Research, Imperial College London, London, UK
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22
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Taljaard M, Li F, Qin B, Cui C, Zhang L, Nicholls SG, Carroll K, Mitchell SL. Methodological challenges in pragmatic trials in Alzheimer's disease and related dementias: Opportunities for improvement. Clin Trials 2021; 19:86-96. [PMID: 34841910 DOI: 10.1177/17407745211046672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS We need more pragmatic trials of interventions to improve care and outcomes for people living with Alzheimer's disease and related dementias. However, these trials present unique methodological challenges in their design, analysis, and reporting-often, due to the presence of one or more sources of clustering. Failure to account for clustering in the design and analysis can lead to increased risks of Type I and Type II errors. We conducted a review to describe key methodological characteristics and obtain a "baseline assessment" of methodological quality of pragmatic trials in dementia research, with a view to developing new methods and practical guidance to support investigators and methodologists conducting pragmatic trials in this field. METHODS We used a published search filter in MEDLINE to identify trials more likely to be pragmatic and identified a subset that focused on people living with Alzheimer's disease or other dementias or included them as a defined subgroup. Pairs of reviewers extracted descriptive information and key methodological quality indicators from each trial. RESULTS We identified N = 62 eligible primary trial reports published across 36 different journals. There were 15 (24%) individually randomized, 38 (61%) cluster randomized, and 9 (15%) individually randomized group treatment designs; 54 (87%) trials used repeated measures on the same individual and/or cluster over time and 17 (27%) had a multivariate primary outcome (e.g. due to measuring an outcome on both the patient and their caregiver). Of the 38 cluster randomized trials, 16 (42%) did not report sample size calculations accounting for the intracluster correlation and 13 (34%) did not account for intracluster correlation in the analysis. Of the 9 individually randomized group treatment trials, 6 (67%) did not report sample size calculations accounting for intracluster correlation and 8 (89%) did not account for it in the analysis. Of the 54 trials with repeated measurements, 45 (83%) did not report sample size calculations accounting for repeated measurements and 19 (35%) did not utilize at least some of the repeated measures in the analysis. No trials accounted for the multivariate nature of their primary outcomes in sample size calculation; only one did so in the analysis. CONCLUSION There is a need and opportunity to improve the design, analysis, and reporting of pragmatic trials in dementia research. Investigators should pay attention to the potential presence of one or more sources of clustering. While methods for longitudinal and cluster randomized trials are well developed, accessible resources and new methods for dealing with multiple sources of clustering are required. Involvement of a statistician with expertise in longitudinal and clustered designs is recommended.
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Affiliation(s)
- Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Bo Qin
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Caroline Cui
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Leyi Zhang
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Susan L Mitchell
- Hebrew Senior Life Marcus Institute for Aging Research, Boston, MA, USA
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23
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Vickery N, Stephens T, du Toit L, van Straaten D, Pearse R, Torborg A, Rolt L, Puchert M, Martin G, Biccard B. Understanding the performance of a pan-African intervention to reduce postoperative mortality: a mixed-methods process evaluation of the ASOS-2 trial. Br J Anaesth 2021; 127:778-788. [PMID: 34446223 DOI: 10.1016/j.bja.2021.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 04/20/2021] [Revised: 06/22/2021] [Accepted: 07/07/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The African Surgical OutcomeS-2 (ASOS-2) trial tested an enhanced postoperative surveillance intervention to reduce postoperative mortality in Africa. We undertook a concurrent evaluation to understand the process of intervention delivery. METHODS Mixed-methods process evaluation, including field notes, interviews, and post-trial questionnaire responses. Qualitative analysis used the framework method with subsequent creation of comparative case studies, grouping hospitals by intervention fidelity. A post-trial questionnaire was developed using initial qualitative analyses. Categorical variables were summarised as count (%) and continuous variables as median (inter-quartile range [IQR]). Odds ratios (OR) were used to rank influences by impact on fidelity. RESULTS The dataset included eight in-depth case studies, and 96 questionnaire responses (response rate 67%) plus intervention fidelity data for each trial site. Overall, 57% (n=55/96) of hospitals achieved intervention delivery using an inclusive definition of fidelity. Delivery of the ASOS-2 interventions and data collection presented a significant burden to the investigators, outstripping limited resources. The influences most associated with fidelity were: surgical staff enthusiasm for the trial (OR=3.0; 95% confidence interval [CI], 1.3-7.0); nursing management support of the trial (OR=2.6; 95% CI, 1.1-6.5); performance of a dummy run (OR=2.6; 95% CI, 1.1-6.1); nursing colleagues seeing the value of the intervention(s) (OR=2.1; 95% CI, 0.9-5.7); and site investigators' belief in the effectiveness of the intervention (OR=3.2; 95% CI, 1.2-9.4). CONCLUSIONS ASOS-2 has proved that coordinated interventional research across Africa is possible, but delivering the ASOS-2 interventions was a major challenge for many investigators. Future improvement science efforts must include better planning for intervention delivery, additional support to investigators, and promotion of strong inter-professional teamwork. CLINICAL TRIAL REGISTRATION ClinicalTrials gov NCT03853824.
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Affiliation(s)
- Nicola Vickery
- University of Cape Town, Department of Anaesthesia and Perioperative Medicine, Cape Town, South Africa; Queen Mary University of London, William Harvey Research Institute, London, UK
| | - Timothy Stephens
- Queen Mary University of London, William Harvey Research Institute, London, UK; Barts Health NHS Trust, Critical Care and Perioperative Medicine Research Group, London, UK.
| | - Leon du Toit
- University of Cape Town, Department of Anaesthesia and Perioperative Medicine, Cape Town, South Africa; Washington University St Louis, Department of Anesthesiology, School of Medicine, St Louis, MO, USA
| | | | - Rupert Pearse
- Queen Mary University of London, William Harvey Research Institute, London, UK
| | - Alexandra Torborg
- Inkosi Albert Luthili Central Hospital, Department of Anaesthesiology, Durban, South Africa; University of KwaZulu-Natal College of Health Sciences, Anaesthesiology and Critical Care, Durban, South Africa
| | - Lucy Rolt
- University of KwaZulu-Natal College of Health Sciences, Anaesthesiology and Critical Care, Durban, South Africa
| | - Mariechen Puchert
- University of Cape Town, Department of Anaesthesia and Perioperative Medicine, Cape Town, South Africa
| | - Graham Martin
- University of Cambridge, The Healthcare Improvement Studies Institute, Cambridge, UK
| | - Bruce Biccard
- University of Cape Town, Department of Anaesthesia and Perioperative Medicine, Cape Town, South Africa; Groote Schuur Hospital, Department of Anaesthesia, Cape Town, South Africa
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24
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Tong G, Seal KH, Becker WC, Li F, Dziura JD, Peduzzi PN, Esserman DA. Impact of complex, partially nested clustering in a three-arm individually randomized group treatment trial: A case study with the wHOPE trial. Clin Trials 2021; 19:3-13. [PMID: 34693748 DOI: 10.1177/17407745211051288] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIMS When participants in individually randomized group treatment trials are treated by multiple clinicians or in multiple group treatment sessions throughout the trial, this induces partially nested clusters which can affect the power of a trial. We investigate this issue in the Whole Health Options and Pain Education trial, a three-arm pragmatic, individually randomized clinical trial. We evaluate whether partial clusters due to multiple visits delivered by different clinicians in the Whole Health Team arm and dynamic participant groups due to changing group leaders and/or participants across treatment sessions during treatment delivery in the Primary Care Group Education arm may impact the power of the trial. We also present a Bayesian approach to estimate the intraclass correlation coefficients. METHODS We present statistical models for each treatment arm of Whole Health Options and Pain Education trial in which power is estimated under different intraclass correlation coefficients and mapping matrices between participants and clinicians or treatment sessions. Power calculations are based on pairwise comparisons. In practice, sample size calculations depend on estimates of the intraclass correlation coefficients at the treatment sessions and clinician levels. To accommodate such complexities, we present a Bayesian framework for the estimation of intraclass correlation coefficients under different participant-to-session and participant-to-clinician mapping scenarios. We simulated continuous outcome data based on various clinical scenarios in Whole Health Options and Pain Education trial using a range of intraclass correlation coefficients and mapping matrices and used Gibbs samplers with conjugate priors to obtain posteriors of the intraclass correlation coefficients under those different scenarios. Posterior means and medians and their biases are calculated for the intraclass correlation coefficients to evaluate the operating characteristics of the Bayesian intraclass correlation coefficient estimators. RESULTS Power for Whole Health Team versus Primary Care Group Education is sensitive to the intraclass correlation coefficient in the Whole Health Team arm. In these two arms, an increased number of clinicians, more evenly distributed workload of clinicians, or more homogeneous treatment group sizes leads to increased power. Our simulation study for the intraclass correlation coefficient estimation indicates that the posterior mean intraclass correlation coefficient estimator has less bias when the true intraclass correlation coefficients are large (i.e. 0.10), but when the intraclass correlation coefficient is small (i.e. 0.01), the posterior median intraclass correlation coefficient estimator is less biased. CONCLUSION Knowledge of intraclass correlation coefficients and the structure of clustering are critical to the design of individually randomized group treatment trials with partially nested clusters. We demonstrate that the intraclass correlation coefficient of the Whole Health Team arm can affect power in the Whole Health Options and Pain Education trial. A Bayesian approach provides a flexible procedure for estimating the intraclass correlation coefficients under complex scenarios. More work is needed to educate the research community about the individually randomized group treatment design and encourage publication of intraclass correlation coefficients to help inform future trial designs.
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Affiliation(s)
- Guangyu Tong
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA.,Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Karen H Seal
- San Francisco VA Health Care System, Integrative Health Service, San Francisco, CA, USA.,Department of Medicine and Psychiatry, University of California-San Francisco, San Francisco, CA, USA
| | - William C Becker
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities and Education Center of Innovation, West Haven, CT, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - James D Dziura
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA.,Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Peter N Peduzzi
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Denise A Esserman
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
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25
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Auriemma CL, Taylor SP, Harhay MO, Courtright KR, Halpern SD. Hospital-free Days: A Pragmatic and Patient-centered Outcome for Trials Among Critically and Seriously Ill Patients. Am J Respir Crit Care Med 2021; 204:902-909. [PMID: 34319848 DOI: 10.1164/rccm.202104-1063pp] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hospital-free days (HFDs), alternatively known as "days alive and outside the hospital," is increasingly used as a primary or secondary outcome in randomized trials among critically and seriously ill patients. This novel outcome measure addresses an existing gap in the availability of patient-centered, reliably obtained outcome measures among patients with acute respiratory failure, advanced lung diseases, lung transplantation, and other serious and critical illnesses. Traditional outcomes such as mortality, organ-failure-free days, and longitudinal patient-reported measures have distinct drawbacks that limit their suitability as endpoints in trials of patients with serious illness, particularly those trials with pragmatic designs. By contrast, HFDs provides a summary measure of important health events and is easily calculated from administrative or electronic health record data, thereby balancing the goals of patient-centeredness and pragmatic measurement. However, before HFDs can be widely adopted as an endpoint in trials of patients with respiratory and critical illnesses, several questions must be addressed regarding the optimal definition, measurement, and analysis of HFDs. In this perspective, we outline important considerations relevant to the use of HFDs as a trial endpoint and suggest directions for further development of the measure.
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Affiliation(s)
- Catherine L Auriemma
- University of Pennsylvania, 6572, Medicine, Philadelphia, Pennsylvania, United States;
| | | | - Michael O Harhay
- University of Pennsylvania, Biostatistics, Epidemiology and Informatics, Philadelphia, Pennsylvania, United States
| | - Katherine R Courtright
- University of Pennsylvania Perelman School of Medicine, 14640, Medicine, Philadelphia, Pennsylvania, United States
| | - Scott D Halpern
- University of Pennsylvania Perelman School of Medicine, 14640, Philadelphia, Pennsylvania, United States
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26
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Brody AA, Barnes DE, Chodosh J, Galvin JE, Hepburn KW, Troxel AB, Hom K, McCarthy EP, Unroe KT. Building a National Program for Pilot Studies of Embedded Pragmatic Clinical Trials in Dementia Care. J Am Geriatr Soc 2021; 68 Suppl 2:S14-S20. [PMID: 32589282 DOI: 10.1111/jgs.16618] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 02/28/2020] [Revised: 04/03/2020] [Accepted: 04/10/2020] [Indexed: 12/24/2022]
Abstract
Sixteen million caregivers currently provide care to more than 5 million persons living with dementia (PLWD) in the United States. Although this population is growing and highly complex, evidence-based management remains poorly integrated within healthcare systems. Therefore, the National Institute on Aging IMPACT Collaboratory was formed to build the nation's ability to conduct embedded pragmatic clinical trials (ePCTs) for PLWD and their caregivers. The pilot core of the IMPACT Collaboratory seeks to provide funds for upward of 40 pilots for ePCTs to accelerate the testing of nonpharmacologic interventions with the goal that these pilots lead to full-scale ePCTs and eventually the embedding of evidence-based care into healthcare systems. The first two challenges for the pilot core in building the pilot study program were (1) to develop a transparent, ethical, and open nationwide process for soliciting, reviewing, and selecting pilot studies; and (2) to begin the process of describing the necessary components of a pilot study for an ePCT. During our initial funding cycle, we received 35 letters of intent, of which 17 were accepted for a full proposal and 14 were submitted. From this process we learned that investigators lack knowledge in ePCTs, many interventions lack readiness for an ePCT pilot study, and many proposed studies lack key pragmatic design elements. We therefore have set three key criteria that future pilot studies must meet at a minimum to be considered viable. We additionally discuss key design decisions investigators should consider in designing a pilot study for an ePCT. J Am Geriatr Soc 68:S14-S20, 2020.
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Affiliation(s)
- Abraham A Brody
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA.,Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, New York, USA
| | - Deborah E Barnes
- Department of Psychiatry and Epidemiology & Biostatistics, University of California, San Francisco School of Medicine, San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Joshua Chodosh
- Division of Geriatric Medicine and Palliative Care, NYU Grossman School of Medicine, New York, New York, USA
| | - James E Galvin
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Andrea B Troxel
- Division of Biostatistics, NYU Grossman School of Medicine, New York, New York, USA
| | - Kimberly Hom
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, New York, New York, USA
| | - Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen T Unroe
- Center for Aging Research, Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana, USA
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27
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Quiñones AR, Mitchell SL, Jackson JD, Aranda MP, Dilworth-Anderson P, McCarthy EP, Hinton L. Achieving Health Equity in Embedded Pragmatic Trials for People Living with Dementia and Their Family Caregivers. J Am Geriatr Soc 2021; 68 Suppl 2:S8-S13. [PMID: 32589281 DOI: 10.1111/jgs.16614] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 02/28/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 11/26/2022]
Abstract
Embedded pragmatic clinical trials (ePCTs) advance research on Alzheimer's disease/Alzheimer's disease and related dementias (AD/ADRD) in real-world contexts; however, health equity issues have not yet been fully considered, assessed, or integrated into ePCT designs. Health disparity populations may not be well represented in ePCTs without special efforts to identify and successfully recruit sites of care that serve larger numbers of these populations. The National Institute on Aging (NIA) Imbedded Pragmatic Alzheimer's disease (AD) and AD-Related Dementias (AD/ADRD) Clinical Trials (IMPACT) Collaboratory's Health Equity Team will contribute to the overall mission of the collaboratory by developing and implementing strategies to address health equity in the conduct of ePCTs and ensure the collaboratory is a national resource for all Americans with dementia. As a first step toward meeting these goals, this article reviews what is currently known about the inclusion of health disparities populations of people living with dementia (PLWD) and their caregivers in ePCTs, highlights unique challenges related to health equity in the conduct of ePCTs, and suggests priority areas in the design and implementation of ePCTs to increase the awareness and avoidance of pitfalls that may perpetuate and magnify healthcare disparities. J Am Geriatr Soc 68:S8-S13, 2020.
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Affiliation(s)
- Ana R Quiñones
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA.,OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, Oregon, USA
| | - Susan L Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan D Jackson
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - María P Aranda
- USC Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA
| | - Peggye Dilworth-Anderson
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ladson Hinton
- Department of Psychiatry and Behavioral Sciences, University of California Davis, Davis, California, USA
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28
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Abstract
BACKGROUND/AIMS Current research largely tends to ignore the drug-testing model that was developed in the "Second World" as an explicit alternative to the randomized controlled trial. This system can be described as "socialist pharmapolitics," accounting for the specific features of state socialism that influenced the development and testing of experimental drugs. The clinical trials model employed in the "Second World" was heavily influenced by the Soviet Union, which was by far the most influential player in the socialist bloc during the Cold War. Based on extensive archival research, this article presents an empirical case of a late Soviet clinical trial as a pragmatic alternative to the randomized controlled trial model. It accounts for the divergences between the official model prescribed by the Soviet authorities and the messy realities of healthcare practice. It further outlines different factors that ultimately shaped how clinical trials were organized in Soviet institutions "on the ground." Accordingly, this article presents a "real-life" history of "socialist pharmapolitics" and outlines the problems that this system faced in practice. METHODS Archival research was conducted at the Russian State Archive of Scientific and Technical Documentation in Moscow. Archival files include scientific, technical, and registration documentation such as biochemical, pharmacological, and clinical descriptions of the experimental drug Meldonium, letters between various hospitals, research institutes and the Soviet regulatory body, as well as 26 reports of completed clinical trials. Manual content analysis was used for the interpretation of results. RESULTS This article presents an empirical case of a late Soviet clinical trial as a pragmatic alternative to the randomized controlled trial model. It demonstrates some key differences from the randomized controlled trial model. This article also highlights some of the discrepancies between the model that was officially prescribed by the Soviet authorities and the realities of experimental drug testing in the Soviet Union in the late 1980s and early 1990s. In particular, it notes some elements of randomization, double-blinding, and the use of placebo that were present in Meldonium trials despite being formally denounced by Soviet bioethics. CONCLUSION The Soviet model for testing experimental drugs differed from the Western one substantially in a number of respects. This difference was not only proclaimed officially by the Soviet authorities, but was for the most part enforced in clinical trials in practice. At the same time, our research demonstrates that there were important differences between the official model and the clinical realities on the ground.
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Affiliation(s)
| | - Alexander Petrenko
- Department of Philosophy, Siberian State Medical University, Tomsk, Russia
| | - Pavel Vasilyev
- Department of History, HSE University, Saint Petersburg, Russia
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Gallis JA, Kusibab K, Egger JR, Olsen MK, Askew S, Steinberg DM, Bennett GG. Can Electronic Health Records Validly Estimate the Effects of Health System Interventions Aimed at Controlling Body Weight? Obesity (Silver Spring) 2020; 28:2107-2115. [PMID: 32985131 PMCID: PMC8351620 DOI: 10.1002/oby.22958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 04/29/2020] [Revised: 06/08/2020] [Accepted: 06/26/2020] [Indexed: 11/12/2022]
Abstract
OBJECTIVE This study aimed to compare weight collected at clinics and recorded in the electronic health record (EHR) with primary study-collected trial weights to assess the validity of using EHR data in future pragmatic weight loss or weight gain prevention trials. METHODS For both the Track and Shape obesity intervention randomized trials, clinic EHR weight data were compared with primary trial weight data over the same time period. In analyzing the EHR weights, intervention effects were estimated on the primary outcome of weight (in kilograms) with EHR data, using linear mixed effects models. RESULTS EHR weight measurements were higher on average and more variable than trial weight measurements. The mean difference and 95% CI were similar at all time points between the estimates using EHR and study-collected weights. CONCLUSIONS The results of this study can be used to help guide the planning of future pragmatic weight-related trials. This study provides evidence that body weight measurements abstracted from the EHR can provide valid, efficient, and cost-effective data to estimate treatment effects from randomized clinical weight loss and weight management trials. However, care should be taken to properly understand the data-generating process and any mechanisms that may affect the validity of these estimates.
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Affiliation(s)
- John A. Gallis
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, United States
- Duke Global Health Institute, Duke University, Durham, NC, United States
| | - Kristie Kusibab
- During the study, Ms. Kusibab was a Master of Science student in the Department of Biostatistics & Bioinformatics at Duke University
- PharPoint Research, Inc., Durham, NC, United States
| | - Joseph R. Egger
- Duke Global Health Institute, Duke University, Durham, NC, United States
| | - Maren K. Olsen
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, United States
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, United States
| | - Sandy Askew
- Duke Global Health Institute, Duke University, Durham, NC, United States
- Duke Global Digital Health Science Center, Duke University, Durham, NC, United States
| | - Dori M. Steinberg
- Duke Global Health Institute, Duke University, Durham, NC, United States
- Duke Global Digital Health Science Center, Duke University, Durham, NC, United States
- Duke School of Nursing, Duke University, Durham, NC, United States
| | - Gary G. Bennett
- Duke Global Health Institute, Duke University, Durham, NC, United States
- Duke Global Digital Health Science Center, Duke University, Durham, NC, United States
- Department of Psychology and Neuroscience, Duke University, Durham, NC, United States
- Corresponding Author Contact Info: Gary G. Bennett, ; 919-668-3420; 116 Allen Building, Box 90024, Durham NC 27708
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Affiliation(s)
- Steve Harris
- Critical Care Department, University College London Hospital, London, UK.
| | - Ed Palmer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Kevin Fong
- Department of Peri-operative Medicine, University College London Hospital, London, UK
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Gill TM, Bhasin S, Reuben DB, Latham NK, Araujo K, Ganz DA, Boult C, Wu AW, Magaziner J, Alexander N, Wallace RB, Miller ME, Travison TG, Greenspan SL, Gurwitz JH, Rich J, Volpi E, Waring SC, Manini TM, Min LC, Teresi J, Dykes PC, McMahon S, McGloin JM, Skokos EA, Charpentier P, Basaria S, Duncan PW, Storer TW, Gazarian P, Allore HG, Dziura J, Esserman D, Carnie MB, Hanson C, Ko F, Resnick NM, Wiggins J, Lu C, Meng C, Goehring L, Fagan M, Correa-de-Araujo R, Casteel C, Peduzzi P, Greene EJ. Effect of a Multifactorial Fall Injury Prevention Intervention on Patient Well-Being: The STRIDE Study. J Am Geriatr Soc 2020; 69:173-179. [PMID: 33037632 PMCID: PMC8178516 DOI: 10.1111/jgs.16854] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/02/2020] [Accepted: 09/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/OBJECTIVES In the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study, a multifactorial intervention was associated with a nonsignificant 8% reduction in time to first serious fall injury but a significant 10% reduction in time to first self-reported fall injury relative to enhanced usual care. The effect of the intervention on other outcomes important to patients has not yet been reported. We aimed to evaluate the effect of the intervention on patient well-being including concern about falling, anxiety, depression, physical function, and disability. DESIGN Pragmatic cluster-randomized trial of 5,451 community-living persons at high risk for serious fall injuries. SETTING A total of 86 primary care practices within 10 U.S. healthcare systems. PARTICIPANTS A random subsample of 743 persons aged 75 and older. MEASUREMENTS The well-being measures, assessed at baseline, 12 months, and 24 months, included a modified version of the Fall Efficacy Scale, Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depression scales, and Late-Life Function and Disability Instrument. RESULTS Participants in the intervention (n = 384) and control groups (n = 359) were comparable in age: mean (standard deviation) of 81.9 (4.7) versus 81.8 (5.0) years. Mean scores were similar between groups at 12 and 24 months for concern about falling, physical function, and disability, whereas the intervention group's mean scores on anxiety and depression were .7 points lower (i.e., better) at 12 months and .6 to .8 points lower at 24 months. For each of these outcomes, differences between the groups' adjusted least square mean changes from baseline to 12 and 24 months, respectively, were quantitatively small. The overall difference in means between groups over 2 years was statistically significant only for depression, favoring the intervention: -1.19 (99% confidence interval, -2.36 to -.02), with 3.5 points representing a minimally important difference. CONCLUSIONS STRIDE's multifactorial intervention to reduce fall injuries was not associated with clinically meaningful improvements in patient well-being.
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Affiliation(s)
- Thomas M Gill
- Yale Claude D. Pepper Older Americans Independence Center, Yale University, New Haven, Connecticut, USA
| | - Shalender Bhasin
- Boston Claude D. Pepper Older Americans Independence Center, Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Nancy K Latham
- Boston Claude D. Pepper Older Americans Independence Center, Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Katy Araujo
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | - David A Ganz
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Geriatric Research, Education and Clinical Center; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Chad Boult
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Albert W Wu
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Jay Magaziner
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | | | - Michael E Miller
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Thomas G Travison
- Boston Claude D. Pepper Older Americans Independence Center, Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Susan L Greenspan
- Pittsburgh Claude D. Pepper Older Americans Independence Center, Division of Geriatrics and Gerontology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jerry H Gurwitz
- Meyers Primary Care Institute, A Joint Endeavor of Reliant Medical Group, Fallon Health and University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jeremy Rich
- HealthCare Partners, El Segundo, California, USA
| | - Elena Volpi
- University of Texas Medical Branch Claude D. Pepper Older Americans Independence Center; Sealy Center on Aging, The University of Texas Medical Branch, Galveston, Texas, USA
| | | | - Todd M Manini
- Department of Aging and Geriatric Research, University of Florida, Gainesville, Florida, USA
| | | | - Jeanne Teresi
- Research Division, Hebrew Home at Riverdale, RiverSpring Health, Bronx, New York, USA
| | | | - Siobhan McMahon
- School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA
| | - Joanne M McGloin
- Yale Claude D. Pepper Older Americans Independence Center, Yale University, New Haven, Connecticut, USA
| | - Eleni A Skokos
- Yale Claude D. Pepper Older Americans Independence Center, Yale University, New Haven, Connecticut, USA
| | - Peter Charpentier
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | - Shehzad Basaria
- Boston Claude D. Pepper Older Americans Independence Center, Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Pamela W Duncan
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Thomas W Storer
- Boston Claude D. Pepper Older Americans Independence Center, Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Priscilla Gazarian
- Brigham and Women's Hospital, Boston, Massachusetts, USA.,University of Massachusetts, Boston, Massachusetts, USA
| | - Heather G Allore
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | - James Dziura
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | - Denise Esserman
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | | | | | - Fred Ko
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Neil M Resnick
- Pittsburgh Claude D. Pepper Older Americans Independence Center, Division of Geriatrics and Gerontology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Charles Lu
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | - Can Meng
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | - Lori Goehring
- Boston Claude D. Pepper Older Americans Independence Center, Research Program in Men's Health: Aging and Metabolism, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Maureen Fagan
- University of Miami Health System, Miami, Florida, USA
| | | | | | - Peter Peduzzi
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
| | - Erich J Greene
- Yale Center for Analytical Sciences, Yale University, New Haven, Connecticut, USA
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Reuben DB, Gill TM, Stevens A, Williamson J, Volpi E, Lichtenstein M, Jennings LA, Tan Z, Evertson L, Bass D, Weitzman L, Carnie M, Wilson N, Araujo K, Charpentier P, Meng C, Greene EJ, Dziura J, Liu J, Unger E, Yang M, Currie K, Lenoir KM, Green ANS, Abraham S, Vernon A, Samper-Ternent R, Raji M, Hirst RM, Galloway R, Finney GR, Ladd I, Rahm AK, Borek P, Peduzzi P. D-CARE: The Dementia Care Study: Design of a Pragmatic Trial of the Effectiveness and Cost Effectiveness of Health System-Based Versus Community-Based Dementia Care Versus Usual Dementia Care. J Am Geriatr Soc 2020; 68:2492-2499. [PMID: 32949145 DOI: 10.1111/jgs.16862] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 07/06/2020] [Revised: 08/26/2020] [Accepted: 08/27/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES Although several approaches have been developed to provide comprehensive care for persons living with dementia (PWD) and their family or friend caregivers, the relative effectiveness and cost effectiveness of community-based dementia care (CBDC) versus health system-based dementia care (CBDC) and the effectiveness of both approaches compared with usual care (UC) are unknown. DESIGN Pragmatic randomized three-arm superiority trial. The unit of randomization is the PWD/caregiver dyad. SETTING Four clinical trial sites (CTSs) based in academic and clinical health systems. PARTICIPANTS A total of 2,150 English- or Spanish-speaking PWD who are not receiving hospice or residing in a nursing home and their caregivers. INTERVENTIONS Eighteen months of (1) HSDC provided by a nurse practitioner or physician's assistant dementia care specialist who works within the health system, or (2) CBDC provided by a social worker or nurse care consultant who works at a community-based organization, or (3) UC with as needed referral to the Alzheimer's Association Helpline. MEASUREMENTS Primary outcomes: PWD behavioral symptoms and caregiver distress as measured by the Neuropsychiatric Inventory Questionnaire (NPI-Q) Severity and Modified Caregiver Strain Index scales. SECONDARY OUTCOMES NPI-Q Distress, caregiver unmet needs and confidence, and caregiver depressive symptoms. Tertiary outcomes: PWD long-term nursing home placement rates, caregiver-reported PWD functional status, cognition, goal attainment, "time spent at home," Dementia Burden Scale-Caregiver, a composite measure of clinical benefit, Quality of Life of persons with dementia, Positive Aspects of Caregiving, and cost effectiveness using intervention costs and Medicare claims. RESULTS The results will be reported in the spring of 2024. CONCLUSION D-CARE will address whether emphasis on clinical support and tighter integration with other medical services has greater benefit than emphasis on social support that is tied more closely to community resources. It will also assess the effectiveness of both interventions compared with UC and will evaluate the cost effectiveness of each intervention.
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Affiliation(s)
- David B Reuben
- Department of Medicine, Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Thomas M Gill
- Department of Internal Medicine, Section of Geriatrics, Yale University, New Haven, Connecticut, USA
| | - Alan Stevens
- Department of Medicine, Baylor Scott & White Health, Temple, Texas, USA
| | - Jeff Williamson
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Elena Volpi
- Department of Internal Medicine, Division of Geriatrics, University of Texas, Medical Branch, Galveston, Texas, USA
| | - Maya Lichtenstein
- Department of Neurology, Geisinger Health, Wilkes Barre, Pennsylvania, USA
| | - Lee A Jennings
- Department of Medicien, Reynolds Section of Geriatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Zaldy Tan
- Department of Medicine, Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Leslie Evertson
- Department of Medicine, Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - David Bass
- Center for Research and Education, Benjamin Rose Institute on Aging, Cleveland, Ohio, USA
| | - Lisa Weitzman
- Center for Research and Education, Benjamin Rose Institute on Aging, Cleveland, Ohio, USA
| | - Martie Carnie
- Center for Patients and Families, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nancy Wilson
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Katy Araujo
- Department of Internal Medicine, Section of Geriatrics, Yale University, New Haven, Connecticut, USA
| | - Peter Charpentier
- Department of Internal Medicine, Section of Geriatrics, Yale University, New Haven, Connecticut, USA
| | - Can Meng
- Department of Internal Medicine, Section of Geriatrics, Yale University, New Haven, Connecticut, USA
| | - Erich J Greene
- Department of Internal Medicine, Section of Geriatrics, Yale University, New Haven, Connecticut, USA
| | - James Dziura
- Department of Internal Medicine, Section of Geriatrics, Yale University, New Haven, Connecticut, USA
| | - Jodi Liu
- Pardee RAND Graduate School, Santa Monica, California, USA
| | - Erin Unger
- Department of Medicine, Division of Geriatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Mia Yang
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Katherine Currie
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Kristin M Lenoir
- Department of Internal Medicine, Section on Gerontology and Geriatric Medicine, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | | | - Sitara Abraham
- Department of Medicine, Baylor Scott & White Health, Temple, Texas, USA
| | - Ashley Vernon
- Department of Medicine, Baylor Scott & White Health, Temple, Texas, USA
| | - Rafael Samper-Ternent
- Department of Internal Medicine, Division of Geriatrics, University of Texas, Medical Branch, Galveston, Texas, USA
| | - Mukaila Raji
- Department of Internal Medicine, Division of Geriatrics, University of Texas, Medical Branch, Galveston, Texas, USA
| | - Roxana M Hirst
- Department of Internal Medicine, Division of Geriatrics, University of Texas, Medical Branch, Galveston, Texas, USA
| | - Rebecca Galloway
- Department of Internal Medicine, Division of Geriatrics, University of Texas, Medical Branch, Galveston, Texas, USA
| | - Glen R Finney
- Department of Neurology, Geisinger Health, Wilkes Barre, Pennsylvania, USA
| | - Ilene Ladd
- Department of Neurology, Geisinger Health, Wilkes Barre, Pennsylvania, USA
| | | | - Pamela Borek
- Department of Neurology, Geisinger Health, Wilkes Barre, Pennsylvania, USA
| | - Peter Peduzzi
- Department of Internal Medicine, Section of Geriatrics, Yale University, New Haven, Connecticut, USA
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Magid KH, Galenbeck E, Levy C. How Pragmatic are Trials in Nursing Home Settings? J Am Med Dir Assoc 2020; 21:1821-3. [PMID: 32859515 DOI: 10.1016/j.jamda.2020.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 11/22/2022]
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Abstract
There has been a good deal of discussion in the literature regarding which subjects are vulnerable in the context of clinical trials. There has been significantly less discussion regarding when and how to include vulnerable subjects in clinical trials. This lack of guidance is a particular problem for trials covered by the US regulations, which mandate strict requirements on the inclusion of three groups: pregnant women/fetuses, prisoners, and children. For the past 30 years, funders, investigators, and institutional review boards have frequently responded to these regulations by excluding pregnant women/fetuses, prisoners, and children from clinical trials. More recent work has emphasized the extent to which a default of exclusion can undermine the value of clinical trials, especially pragmatic trials. A default of exclusion also has the potential to undermine the interests of vulnerable groups, in both the short and the long term. These concerns raise the need for guidance on how to satisfy existing US regulations, while minimizing their negative impact on the value of clinical trials and the interests of vulnerable groups. The present manuscript thus describes a six-step decision procedure that institutional review boards can use to determine when and how to include vulnerable subjects in clinical trials, including pragmatic trials, that are covered by US regulations.
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Affiliation(s)
- David Wendler
- Department of Bioethics, National Institutes of Health, Bethesda, MD, USA
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Heck PR, Chabris CF, Watts DJ, Meyer MN. Objecting to experiments even while approving of the policies or treatments they compare. Proc Natl Acad Sci U S A 2020; 117:18948-50. [PMID: 32719133 DOI: 10.1073/pnas.2009030117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We resolve a controversy over two competing hypotheses about why people object to randomized experiments: 1) People unsurprisingly object to experiments only when they object to a policy or treatment the experiment contains, or 2) people can paradoxically object to experiments even when they approve of implementing either condition for everyone. Using multiple measures of preference and test criteria in five preregistered within-subjects studies with 1,955 participants, we find that people often disapprove of experiments involving randomization despite approving of the policies or treatments to be tested.
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Zhang X, Ma Y, Chen H, Lou Y, Ji L, Chen L. A pragmatic study of mid-mixture insulin and basal insulin treatment in patients with type 2 diabetes uncontrolled with oral antihyperglycaemic medications: A lesson from real-world experience. Diabetes Obes Metab 2020; 22:1436-1442. [PMID: 32267071 PMCID: PMC7384022 DOI: 10.1111/dom.14052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/23/2020] [Accepted: 04/01/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chinese guidelines for the treatment of type 2 diabetes (T2D) recommend basal or premixed insulins as insulin starters after failed oral antihyperglycaemic medication (OAM). This pragmatic study compared effectiveness and safety of add-on basal insulin analog (BI) and mid-mixture insulin analog (MMI; 50:50 premixed insulin) as starter insulin regimens in Chinese patients with T2D in a real-world setting. MATERIALS AND METHODS This was a multicentre, open-label, randomized, parallel, pragmatic trial. Patients receiving OAMs were randomized 1:1 to BI (n = 410) or MMI (n = 404) for 24 weeks. Insulin titration and OAM adjustment were determined by investigators following usual standard-of-care. The primary outcome was change in glycated haemoglobin (HbA1c) from baseline. RESULTS Least-squares mean changes in HbA1c from baseline to week 24 were -2.00% and -2.15% for BI and MMI groups, respectively (P = .13). The MMI group demonstrated a greater reduction in concomitant OAM therapies used than BI group (53.8% vs. 35.3%, respectively; P < .001). Very limited daily insulin dose increments were observed from baseline to week 24 in both BI and MMI groups (2.5 U/day and 1.8 U/day, respectively). Although both insulin analogs were well-tolerated without severe hypoglycaemia, small weight gains were seen with both treatments. Higher total hypoglycaemia rates were noticed with the MMI group, while nocturnal hypoglycaemia events were comparable. CONCLUSIONS In real-world settings, BI and MMI provided similar improvement in glucose control without conceding hypoglycaemia. The BI group received a greater number of OAMs in real-world settings. Limited insulin dose titration was observed, while more adjustments occurred with OAM usage.
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Affiliation(s)
- Xiaomei Zhang
- Department of EndocrinologyPeking University International HospitalBeijingChina
| | - Yujin Ma
- Department of EndocrinologyFirst Hospital, affiliate with Henan University of Science and TechnologyLuoyangChina
| | - Hong Chen
- Lilly Suzhou Pharmaceutical Co. LtdShanghaiChina
| | - Ying Lou
- Lilly Suzhou Pharmaceutical Co. LtdShanghaiChina
| | - Linong Ji
- Department of EndocrinologyPeking University People’s HospitalBeijingChina
| | - Lulu Chen
- Department of Endocrinology, Hubei Provincial, Clinical Research Center for Diabetes and Metabolic DisordersTongji Medical College, Union Hospital, Huazhong University of Science and TechnologyWuhanChina
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Callahan CM, Torke AM, Alder CA, Broughton JA, Mitchell SL. Training the Workforce to Conduct Embedded Pragmatic Clinical Trials to Improve Care for People Living with Dementia and Their Caregivers. J Am Geriatr Soc 2020; 68 Suppl 2:S21-S27. [PMID: 32589278 DOI: 10.1111/jgs.16615] [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: 02/28/2020] [Revised: 04/28/2020] [Accepted: 04/30/2020] [Indexed: 11/27/2022]
Abstract
The National Institute on Aging IMbedded Pragmatic Alzheimer's Disease and Alzheimer's Disease-Related Dementias Clinical Trials (IMPACT) Collaboratory serves as a national resource for the conduct of embedded pragmatic clinical trials to improve the care of people living with dementia (PLWD) in partnership with the healthcare systems that serve them. Inherent in this objective is the need to train and support a cadre of investigators prepared to conduct this work now and in the future. The Training Core of the IMPACT Collaboratory supports the training of investigators to become experts in this field through three objectives: (1) curricula development and dissemination; (2) network generation and navigation; and (3) a career development award program. The innovative approach of the Training Core will require developing content and providing training experiences that recognize the unique challenges of research at the intersection of health systems, pragmatic trials, and PLWD and their caregivers. Ultimately, we seek to build the nation's capacity to conduct research that bridges the gaps between efficacy studies to effectiveness research to implementation science. Although foundational resources in the methods of each of these areas are already available, few actually focus on pragmatic trials embedded within healthcare systems that focus on PLWD. To bring new interventions for PLWD from efficacy to widespread implementation, researchers must build diffusability, adaptability, heterogeneity, and scalability into the design of the intervention. In achieving these objectives, the Training Core will utilize the network of investigators, institutions, and stakeholders represented in the IMPACT Collaboratory. J Am Geriatr Soc 68:S21-S27, 2020.
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Affiliation(s)
- Christopher M Callahan
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA.,Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Alexia M Torke
- Indiana University Center for Aging Research, Indianapolis, Indiana, USA.,Regenstrief Institute, Inc., Indianapolis, Indiana, USA.,Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, Indiana, USA
| | - Catherine A Alder
- Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA
| | - Jessica A Broughton
- Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, Indiana, USA
| | - Susan L Mitchell
- Hebrew Senior Life Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Last BS, Rudd BN, Gregor CA, Kratz HE, Jackson K, Berkowitz S, Zinny A, Cliggitt LP, Adams DR, Walsh LM, Beidas RS. Sociodemographic characteristics of youth in a trauma focused-cognitive behavioral therapy effectiveness trial in the city of Philadelphia. J Community Psychol 2020; 48:1273-1293. [PMID: 31872896 PMCID: PMC7261621 DOI: 10.1002/jcop.22306] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 10/25/2019] [Accepted: 12/05/2019] [Indexed: 05/13/2023]
Abstract
While randomized controlled trials of trauma-focused cognitive behavioral therapy (TF-CBT) have demonstrated efficacy for youth with posttraumatic stress disorder, TF-CBT effectiveness trials typically show attenuated outcomes. This decrease in effectiveness may be due to the differences in sociodemographic characteristics of youth in these trials; youth in efficacy trials are more often white and middle-income, whereas youth in effectiveness trials are more often racial/ethnic minorities, of low socioeconomic status (SES) and live in high crime neighborhoods. In this study-drawn from an effectiveness trial of TF-CBT in community mental health clinics across Philadelphia-we describe the sociodemographic characteristics of enrolled youth. We measured neighborhood SES by matching participants' addresses to American Community Survey data from their Census tracts, housing stability using the National Outcomes Measurement System, and neighborhood violence using police department crime statistics. Our results suggest that the majority of youth presenting for TF-CBT in mental health clinics in the City of Philadelphia live in poor and high-crime neighborhoods, experience substantial housing instability, and are predominantly ethnic and racial minorities. Thus, youth presenting for treatment experience significant racial and socioeconomic adversity. We also explored the association between these characteristics and youth symptom severity upon presenting for treatment. These factors were not associated with youth symptom severity or overall mental health functioning in our sample (with small effect sizes and p > .05 for all). Implications for future research, such as the need for efficacy and effectiveness trials to more fully characterize their samples and the need for pragmatic trials are discussed.
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Affiliation(s)
- Briana S. Last
- Department of Psychology, School of Arts and Sciences, The University of Pennsylvania
| | - Brittany N. Rudd
- Department of Psychiatry, Perelman School of Medicine, The University of Pennsylvania
| | - Courtney A. Gregor
- Department of Psychiatry, Perelman School of Medicine, The University of Pennsylvania
| | | | | | | | | | | | | | | | - Rinad S. Beidas
- Department of Psychiatry, Perelman School of Medicine, The University of Pennsylvania
- Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania
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Spence J, Ioannidis JPA, Avidan MS. Achieving balance with power: lessons from the Balanced Anaesthesia Study. Br J Anaesth 2020; 124:366-370. [PMID: 31973826 DOI: 10.1016/j.bja.2019.12.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 12/16/2019] [Accepted: 12/19/2019] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jessica Spence
- Departments of Anesthesia, Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University and Population Health Research Institute, Hamilton, ON, Canada.
| | - John P A Ioannidis
- Departments of Medicine, Health Research and Policy (Epidemiology), Statistics and Biomedical Data Sciences and Meta-Research Innovation Center at Stanford, Stanford University, Palo Alto, CA, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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Gill TM, McGloin JM, Shelton A, Bianco LM, Skokos EA, Latham NK, Ganz DA, Nyquist LV, Wallace RB, Carnie MB, Dykes PC, Goehring LA, Doyle M, Charpentier PA, Greene EJ, Araujo KL. Optimizing Retention in a Pragmatic Trial of Community-Living Older Persons: The STRIDE Study. J Am Geriatr Soc 2020; 68:1242-1249. [PMID: 32212395 DOI: 10.1111/jgs.16356] [Citation(s) in RCA: 7] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/15/2020] [Accepted: 01/16/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study is testing the effectiveness of a multifactorial intervention to prevent serious fall injuries. Our aim was to describe procedures that were implemented to optimize participant retention; report retention yields by age, sex, clinical site, and follow-up time; provide reasons for study withdrawals; and highlight the successes and lessons learned from the STRIDE retention efforts. DESIGN Pragmatic cluster randomized trial. SETTING A total of 86 primary care practices within 10 US healthcare systems. PARTICIPANTS A total of 5451 community-living persons, 70 years of age or older, at high risk for serious fall injuries. MEASUREMENTS Study outcomes were collected every 4 months by a central call center. Reconsent was required to extend follow-up beyond the originally planned 36 months. RESULTS Over a median follow-up of 3.2 years (interquartile range = 2.8-3.7 y), 439 (8.1%) participants died and 600 (11.0%) withdrew their consent or did not reconsent to extend follow-up beyond 36 months, yielding rates (per 100 person-years) of deaths and withdrawals of 2.6 and 3.6, respectively. The withdrawal rate increased with advancing age, was comparable for men and women, and did not differ much by clinical site. The most common reasons for withdrawal were illness and unable to contact for reconsent at 36 months. Completion of the follow-up interviews was greater than 93% at each time point. Most participants completed all (71.8%) or all but one (9.2%) of the follow-up interviews. The most common reason for not completing a follow-up interview was unable to contact, with rates ranging from 2.8% at 40 months to 4.6% at 20 months. CONCLUSION Completion of the thrice-yearly follow-up interviews in STRIDE was high, and retention of participants over 44 months exceeded the original projections. The procedures used in STRIDE, together with lessons learned, should assist other investigators who are planning or conducting large pragmatic trials of vulnerable older persons. J Am Geriatr Soc 68:1242-1249, 2020.
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Affiliation(s)
- Thomas M Gill
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Joanne M McGloin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Amy Shelton
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Luann M Bianco
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Eleni A Skokos
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - David A Ganz
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA, Los Angeles, California.,VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Linda V Nyquist
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | | | | | | | | | - Margaret Doyle
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Peter A Charpentier
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Erich J Greene
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Katy L Araujo
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Abstract
Clinical trials embedded in health systems can randomize large populations using automated data sources to determine trial eligibility and assess outcomes. The suicide prevention outreach trial used real-world data for trial design and randomized 18,868 individuals in four health systems using patient-reported thoughts of death or self-harm (Patient Health Questionnaire item 9). This took 3.5 years. We consider if using predictive analytics, that is, suicide risk estimates based on prediction models, could improve trial "efficiency." We used data on mental health outpatient visits between 1 January 2009 and 30 September 2017 in seven health systems (HealthPartners; Henry Ford Health System; and Colorado, Hawaii, Northwest, Southern California, and Washington Kaiser Permanente regions). We used a suicide risk prediction model developed in these same systems. We compared five trial designs with different eligibility criteria: a response of a 2 or 3 on Patient Health Questionnaire item 9, a response of a 3, suicide risk score above 90th, 95th, or 99th percentile. We compared the sample that met each criterion, 90-day suicide attempt rate following first eligible visit, and necessary sample sizes to detect a 15%, 25%, and 35% relative reduction in the suicide attempt rate, assuming 90% power, for each eligibility criterion. Our sample included 24,355,599 outpatient visits. Despite wide-spread use of Patient Health Questionnaire, 21,026,985 (86.3%) visits did not have a recorded Patient Health Questionnaire. Of the 2,928,927 individuals in our sample, 109,861 had a recorded Patient Health Questionnaire item 9 response of a 2 or 3 over the study years with a 1.40% 90-day suicide attempt rate and 50,047 had a response of a 3 (suicide attempt rate 1.98%). More patients met criteria requiring a certain risk score or higher: 331,273 had a 90th percentile risk score or higher (suicide attempt rate: 1.36%); 182,316 a 95th percentile or higher (suicide attempt rate 2.16%), and 78,655 a 99th percentile or higher (suicide attempt rate: 3.95%). Eligibility criterion of a Patient Health Questionnaire item 9 response of a 2 or 3 would require randomizing 44,081 individuals (40.2% of eligible population in our sample); eligibility criterion of a 3 would require 31,024 individuals (62.0% of eligible population). Eligibility criterion of a suicide risk score of 90th percentile or higher would require 45,675 individuals (13.8% of eligible population), 95th percentile 28,699 individuals (15.7% of eligible population), and 99th percentile 15,509 (19.7% of eligible population). A suicide risk prediction calculator could improve trial "efficiency"; identifying more individuals at increased suicide risk than relying on patient-report. It is an open scientific question if individuals identified using predictive analytics would respond differently to interventions than those identified by more traditional means.
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Affiliation(s)
- Susan M Shortreed
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Gregory E Simon
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
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Abstract
Pragmatic or practice-oriented comparative effectiveness trials may be conducted to fill the evidence gaps that are revealed after the private sector has performed the trials needed for bringing their product to the market. A tool of increasing importance to identify such evidence gaps is resulting from health technology assessments (HTA) whereby the data derived from clinical research are examined in a systematic manner with reference to effect, safety, as well as additional parameters. Practice-oriented trials are informative for healthcare decision makers, practice-changing and may even be cost-saving for the healthcare payers. There are however only a limited number of funding sources for such trials. Public and private healthcare payers should stimulate the conduct of practice-oriented trials in their effort to maximize patient benefit within the limitation of the available resources. Pragmatic randomized trials can be performed at low cost when based on existing coded electronic health records and as well health registries. Public health decision makers are increasingly taking advantage of results from health technology assessments to support priority setting. In accordance with this it would appear reasonable that decision makers should get more involved in priority setting and funding also in the field of clinical research in order to provide further evidence needed for assessments, reassessments, and subsequent qualified decisions and resource allocations in health care. A closer dialogue and collaboration between the clinical research and HTA communities would facilitate a more efficient utilization of such opportunities.
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Christian JB, Brouwer ES, Girman CJ, Bennett D, Davis KJ, Dreyer NA. Masking in Pragmatic Trials: Who, What, and When to Blind. Ther Innov Regul Sci 2020; 54:431-436. [PMID: 32072597 DOI: 10.1007/s43441-019-00073-7] [Citation(s) in RCA: 7] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 03/20/2019] [Indexed: 10/25/2022]
Abstract
Masking (or blinding) of treatment assignment is routinely implemented in classical randomized clinical trials (RCTs) to isolate the effect of the intervention itself and to minimize the potential for bias that could occur with traditional trials. Such biases could be introduced with the conduct, assessment of endpoints, management of conditions, analysis, and reporting when the treatment assignments are known. However, masking of treatments is not only complex but it hinders how generalizable the findings are to the "real world" clinical setting. Pragmatic RCTs (pRCTs) are intended to evaluate the effects of interventions within routine medical care, and as such, do not typically mask treatment groups; moreover, pRCTs assess comparators that are available in routine medical practice, not masked placebos. Whether pRCTs should be masked if intended for regulatory or other purposes has recently been questioned. The literature on pRCTs, while extensive, does not address how much actual benefit is gained from masking outcomes and how masking may affect the "real world" nature of a study. Here, we propose an approach to evaluate sources of bias, describe stakeholders in the conduct of pRCTs who are most likely affected, and offer a framework for considering how masking may be implemented effectively while maintaining generalizability.
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Affiliation(s)
- Jennifer B Christian
- Center for Advanced Evidence Generation, IQVIA, 4820 Emperor Boulevard, Durham, NC, 27703, USA.
| | - Emily S Brouwer
- Takeda Pharmaceuticals International Co, Global Outcomes Research and Epidemiology, Cambridge, MA, USA
| | | | - Dimitri Bennett
- Epidemiology Department, Takeda Pharmaceuticals, Cambridge, MA, USA
| | - Kourtney J Davis
- Global Epidemiology, Janssen Pharmaceuticals, Titusville, NJ instead of Swarthmore, USA
| | - Nancy A Dreyer
- Center for Advanced Evidence Generation, IQVIA, 4820 Emperor Boulevard, Durham, NC, 27703, USA
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44
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Divney AA, Lopez PM, Huang TT, Thorpe LE, Trinh-Shevrin C, Islam NS. Research-grade data in the real world: challenges and opportunities in data quality from a pragmatic trial in community-based practices. J Am Med Inform Assoc 2019; 26:847-854. [PMID: 31181144 PMCID: PMC6696500 DOI: 10.1093/jamia/ocz062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 01/09/2019] [Revised: 04/12/2019] [Accepted: 04/16/2019] [Indexed: 12/17/2022] Open
Abstract
Randomized controlled trials face cost, logistic, and generalizability limitations, including difficulty engaging racial/ethnic minorities. Real-world data (RWD) from pragmatic trials, including electronic health record (EHR) data, may produce intervention evaluation findings generalizable to diverse populations. This case study of Project IMPACT describes unique barriers and facilitators of optimizing RWD to improve health outcomes and advance health equity in small immigrant-serving community-based practices. Project IMPACT tested the effect of an EHR-based health information technology intervention on hypertension control among small urban practices serving South Asian patients. Challenges in acquiring accurate RWD included EHR field availability and registry capabilities, cross-sector communication, and financial, personnel, and space resources. Although using RWD from community-based practices can inform health equity initiatives, it requires multidisciplinary collaborations, clinic support, procedures for data input (including social determinants), and standardized field logic/rules across EHR platforms.
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Affiliation(s)
- Anna A Divney
- CUNY Graduate School of Public Health and Health Policy, Center for Systems and Community Design, New York, New York, USA
- NYU-CUNY Prevention Research Center, New York, New York, USA
| | - Priscilla M Lopez
- NYU-CUNY Prevention Research Center, New York, New York, USA
- Department of Population Health, NYU School of Medicine, New York, New York, USA
| | - Terry T Huang
- CUNY Graduate School of Public Health and Health Policy, Center for Systems and Community Design, New York, New York, USA
- NYU-CUNY Prevention Research Center, New York, New York, USA
| | - Lorna E Thorpe
- NYU-CUNY Prevention Research Center, New York, New York, USA
- Department of Population Health, NYU School of Medicine, New York, New York, USA
| | - Chau Trinh-Shevrin
- NYU-CUNY Prevention Research Center, New York, New York, USA
- Department of Population Health, NYU School of Medicine, New York, New York, USA
| | - Nadia S Islam
- NYU-CUNY Prevention Research Center, New York, New York, USA
- Department of Population Health, NYU School of Medicine, New York, New York, USA
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45
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Meyer MN, Heck PR, Holtzman GS, Anderson SM, Cai W, Watts DJ, Chabris CF. Objecting to experiments that compare two unobjectionable policies or treatments. Proc Natl Acad Sci U S A 2019; 116:10723-10728. [PMID: 31072934 PMCID: PMC6561206 DOI: 10.1073/pnas.1820701116] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Randomized experiments have enormous potential to improve human welfare in many domains, including healthcare, education, finance, and public policy. However, such "A/B tests" are often criticized on ethical grounds even as similar, untested interventions are implemented without objection. We find robust evidence across 16 studies of 5,873 participants from three diverse populations spanning nine domains-from healthcare to autonomous vehicle design to poverty reduction-that people frequently rate A/B tests designed to establish the comparative effectiveness of two policies or treatments as inappropriate even when universally implementing either A or B, untested, is seen as appropriate. This "A/B effect" is as strong among those with higher educational attainment and science literacy and among relevant professionals. It persists even when there is no reason to prefer A to B and even when recipients are treated unequally and randomly in all conditions (A, B, and A/B). Several remaining explanations for the effect-a belief that consent is required to impose a policy on half of a population but not on the entire population; an aversion to controlled but not to uncontrolled experiments; and a proxy form of the illusion of knowledge (according to which randomized evaluations are unnecessary because experts already do or should know "what works")-appear to contribute to the effect, but none dominates or fully accounts for it. We conclude that rigorously evaluating policies or treatments via pragmatic randomized trials may provoke greater objection than simply implementing those same policies or treatments untested.
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Affiliation(s)
- Michelle N Meyer
- Center for Translational Bioethics and Health Care Policy, Geisinger Health System, Danville, PA 17821;
| | - Patrick R Heck
- Center for Translational Bioethics and Health Care Policy, Geisinger Health System, Danville, PA 17821
- Autism and Developmental Medicine Institute, Geisinger Health System, Lewisburg, PA 17837
| | - Geoffrey S Holtzman
- Center for Translational Bioethics and Health Care Policy, Geisinger Health System, Danville, PA 17821
- Autism and Developmental Medicine Institute, Geisinger Health System, Lewisburg, PA 17837
| | - Stephen M Anderson
- Center for Translational Bioethics and Health Care Policy, Geisinger Health System, Danville, PA 17821
- Autism and Developmental Medicine Institute, Geisinger Health System, Lewisburg, PA 17837
| | - William Cai
- New York City Lab, Microsoft Research, New York, NY 10011
| | - Duncan J Watts
- New York City Lab, Microsoft Research, New York, NY 10011
| | - Christopher F Chabris
- Autism and Developmental Medicine Institute, Geisinger Health System, Lewisburg, PA 17837
- Institute for Advanced Study in Toulouse, 31015 Toulouse, France
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Abstract
Objectives: This scoping review evaluates two decades of methodological advances made by “whole systems research” (WSR) pioneers in the fields of traditional, complementary, and integrative medicine (TCIM). Rooted in critiques of the classical randomized controlled trial (RCT)'s suitability for evaluating holistic, complex TCIM interventions, WSR centralizes the principle of “model validity,” representing a “fit” between research design and therapeutic paradigm. Design: In consultation with field experts, 41 clinical research exemplars were selected for review from across 13 TCIM disciplines, with the aim of mapping the range and methodological characteristics of WSR studies. Using an analytic charting approach, these studies' primary and secondary features are characterized with reference to three focal areas: research method, intervention design, and outcome assessment. Results: The reviewed WSR exemplars investigate a wide range of multimodal and multicomponent TCIM interventions, typified by wellness-geared, multitarget, and multimorbid therapeutic aims. Most studies include a behavioral focus, at times in multidisciplinary or team-based contexts. Treatments are variously individualized, often with reference to “dual” (biomedical and paradigm-specific) diagnoses. Prospective and retrospective study designs substantially reflect established biomedical research methods. Pragmatic, randomized, open label comparative effectiveness designs with “usual care” comparators are most widely used, at times with factorial treatment arms. Only two studies adopt a double-blind, placebo-controlled RCT format. Some cohort-based controlled trials engage nonrandomized allocation strategies (e.g., matched controls, preference-based assignment, and minimization); other key designs include single-cohort pre–post studies, modified n-of-1 series, case series, case report, and ethnography. Mixed methods designs (i.e., qualitative research and economic evaluations) are evident in about one-third of exemplars. Primary and secondary outcomes are predominantly assessed, at multiple intervals, through patient-reported measures for symptom severity, quality of life/wellness, and/or treatment satisfaction; some studies concurrently evaluate objective outcomes. Conclusions: Aligned with trends emphasizing “fit-for-purpose” research designs to study the “real-world” effectiveness of complex, personalized clinical interventions, WSR has emerged as a maturing scholarly discipline. The field is distinguished by its patient-centered salutogenic focus and engagement with nonbiomedical diagnostic and treatment frameworks. The rigorous pursuit of model validity may be further advanced by emphasizing complex analytic models, paradigm-specific outcome assessment, inter-rater reliability, and ethnographically informed designs. Policy makers and funders seeking to support best practices in TCIM research may refer to this review as a key resource.
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Affiliation(s)
- Nadine Ijaz
- 1 Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | | | - Charles Elder
- 3 Kaiser Permanente Center for Health Research, Portland, OR
| | - John Weeks
- 4 johnweeks-integrator.com, Editor-in-Chief, JACM, Seattle, WA
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47
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Schloss J, McIntyre E, Steel A, Bradley R, Harnett J, Reid R, Hawrelak J, Goldenberg J, Van De Venter C, Cooley K. Lessons from Outside and Within: Exploring Advancements in Methodology for Naturopathic Medicine Clinical Research. J Altern Complement Med 2019; 25:135-140. [PMID: 30785314 PMCID: PMC6424155 DOI: 10.1089/acm.2018.0403] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introduction: Naturopathy is a mixture of both traditional and complementary medicine. It incorporates a broad set of health care practices that may or may not be traditional to that country or conventional medicine and are not fully integrated into the dominant health care system. Research required to evaluate or substantiate naturopathic medicine may not fall under the testing of randomized clinical trials, which opens up discussions on what is the best practice for research in naturopathic medicine. Discussion: Not only do advances in health research methodology offer important opportunities to progress naturopathic research, there are also areas where the unique characteristics of naturopathic philosophy and practice can impact other areas of health research. Some of the new advances in health research methodology involve whole-system research, pragmatic trials, template for intervention description and replication protocols for complex interventions, patient-centered care models, and the pragmatic-explanatory continuum indicator summary tool for designing pragmatic trials. Discussion and critique of these health-related methodologies shows that these research methods are more suited for the philosophy and treatment options that naturopathy is based on. Conclusions: Successful implementation of naturopathic research methodologies, and translation and dissemination of research will require a substantial paradigm shift in which naturopathic practitioners adopt a greater level of responsibility for developing an evidence base for naturopathic medicine.
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Affiliation(s)
- Janet Schloss
- 1 Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Faculty of Health, Ultimo, Australia.,2 Office of Research, Endeavour College of Natural Health, Fortitude Valley, Australia
| | - Erica McIntyre
- 1 Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Faculty of Health, Ultimo, Australia
| | - Amie Steel
- 1 Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Faculty of Health, Ultimo, Australia.,2 Office of Research, Endeavour College of Natural Health, Fortitude Valley, Australia
| | - Ryan Bradley
- 1 Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Faculty of Health, Ultimo, Australia.,3 Helfgott Research Institute, National University of Natural Medicine, Portland, OR
| | - Joanna Harnett
- 1 Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Faculty of Health, Ultimo, Australia.,4 Faculty of Pharmacy, University of Sydney, Sydney, Australia
| | - Rebecca Reid
- 1 Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Faculty of Health, Ultimo, Australia.,2 Office of Research, Endeavour College of Natural Health, Fortitude Valley, Australia
| | - Jason Hawrelak
- 1 Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Faculty of Health, Ultimo, Australia.,5 College of Health and Medicine, University of Tasmania, Hobart, Australia
| | - Joshua Goldenberg
- 1 Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Faculty of Health, Ultimo, Australia.,6 Department of Naturopathy, Bastyr University, Kenmore, WA USA
| | - Claudine Van De Venter
- 1 Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Faculty of Health, Ultimo, Australia.,7 Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Kieran Cooley
- 1 Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, Faculty of Health, Ultimo, Australia.,8 Office of Research, Canadian College of Naturopathic Medicine, North York, Canada
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Heddini A, Sundh J, Ekström M, Janson C. Effectiveness trials: critical data to help understand how respiratory medicines really work? Eur Clin Respir J 2019; 6:1565804. [PMID: 30728925 PMCID: PMC6352944 DOI: 10.1080/20018525.2019.1565804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/03/2019] [Indexed: 11/18/2022] Open
Abstract
Most of the information about the benefits, safety aspects, and cost effectiveness of pharmacological treatment in the respiratory field has been obtained from traditional efficacy studies, such as randomised controlled trials (RCT). The highly controlled environment of an RCT does not always reflect everyday practice. The collection, analysis, and application of effectiveness data to generate Real World Evidence (RWE) through pragmatic trials or observational studies therefore has the potential to improve decision making by regulators, payers, and clinicians. Despite calls for more RWE, effectiveness data are not widely used in decision making in the respiratory field. Recent advances in data capture, curation, and storage combined with new analytical tools have now made it feasible for effectiveness data to become routine sources of evidence to supplement traditional efficacy data. In this paper, we will examine some of the current data gaps, diverse types of effectiveness data, look at proposed frameworks for the positioning of effectiveness data, as well as provide examples from therapeutic areas. We will give examples of both previous effectiveness studies and studies that are ongoing within the respiratory field. Effectiveness data hold the potential to address several evidentiary gaps related to the effectiveness, safety, and value of treatments in patients with respiratory diseases.
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Affiliation(s)
| | - Josefin Sundh
- Department of Respiratory Medicine, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Magnus Ekström
- Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy & Sleep Research, Uppsala University, Uppsala, Sweden
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49
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Klein-Laansma CT, Jong M, von Hagens C, Jansen JPCH, van Wietmarschen H, Jong MC. Semi-Individualized Homeopathy Add-On Versus Usual Care Only for Premenstrual Disorders: A Randomized, Controlled Feasibility Study. J Altern Complement Med 2018; 24:684-693. [PMID: 29565636 DOI: 10.1089/acm.2017.0388] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Premenstrual syndrome and premenstrual dysphoric disorder (PMS/PMDD) bother a substantial number of women. Homeopathy seems a promising treatment, but it needs investigation using reliable study designs. The feasibility of organizing an international randomized pragmatic trial on a homeopathic add-on treatment (usual care [UC] + HT) compared with UC alone was evaluated. DESIGN A multicenter, randomized, controlled pragmatic trial with parallel groups. SETTINGS/LOCATION The study was organized in general and private homeopathic practices in the Netherlands and Sweden and in an outpatient university clinic in Germany. SUBJECTS Women diagnosed as having PMS/PMDD, based on prospective daily rating by the daily record of severity of problems (DRSP) during a period of 2 months, were included and randomized. INTERVENTIONS Women were to receive UC + HT or UC for 4 months. Homeopathic medicine selection was according to a previously tested prognostic questionnaire and electronic algorithm. Usual care was as provided by the women's general practitioner according to their preferences. OUTCOME MEASURES Before and after treatment, the women completed diaries (DRSP), the measure yourself concerns and well-being, and other questionnaires. Intention-to-treat (ITT) and per protocol (PP) analyses were performed. RESULTS In Germany, the study could not proceed because of legal limitations. In Sweden, recruitment proved extremely difficult. In the Netherlands and Sweden, 60 women were randomized (UC + HT: 28; UC: 32), data of 47/46 women were analyzed (ITT/PP). After 4 months, relative mean change of DRSP scores in the UC + HT group was significantly better than in the UC group (p = 0.03). CONCLUSIONS With respect to recruitment and different legal status, it does not seem feasible to perform a larger, international, pragmatic randomized trial on (semi-)individualized homeopathy for PMS/PMDD. Since the added value of HT compared with UC was demonstrated by significant differences in symptom score changes, further studies are warranted.
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Affiliation(s)
| | - Mats Jong
- 2 Department of Nursing, Mid-Sweden University , Sundsvall, Sweden
| | - Cornelia von Hagens
- 3 Naturopathy and Integrative Medicine, Department of Gynecological Endocrinology and Reproductive Medicine, University Women's Hospital , Universitätsfrauenklinik Heidelberg, Heidelberg, Germany
| | | | | | - Miek C Jong
- 1 Department of Health and Nutrition, Louis Bolk Institute , Bunnik, The Netherlands .,2 Department of Nursing, Mid-Sweden University , Sundsvall, Sweden
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Ali SA, Kloseck M, Lee K, Walsh KE, MacDermid JC, Fitzsimmons D. Evaluating the design and reporting of pragmatic trials in osteoarthritis research. Rheumatology (Oxford) 2018; 57:59-63. [PMID: 28371879 PMCID: PMC5850497 DOI: 10.1093/rheumatology/kex050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 09/01/2016] [Revised: 02/13/2017] [Indexed: 12/30/2022] Open
Abstract
Objectives Among the challenges in health research is translating interventions from controlled experimental settings to clinical and community settings where chronic disease is managed daily. Pragmatic trials offer a method for testing interventions in real-world settings but are seldom used in OA research. The aim of this study was to evaluate the literature on pragmatic trials in OA research up to August 2016 in order to identify strengths and weaknesses in the design and reporting of these trials. Methods We used established guidelines to assess the degree to which 61 OA studies complied with pragmatic trial design and reporting. We assessed design according to the pragmatic-explanatory continuum indicator summary and reporting according to the pragmatic trials extension of the CONsolidated Standards of Reporting Trials guidelines. Results None of the pragmatic trials met all 11 criteria evaluated and most of the trials met between 5 and 8 of the criteria. Criteria most often unmet pertained to practitioner expertise (by requiring specialists) and criteria most often met pertained to primary outcome analysis (by using intention-to-treat analysis). Conclusion Our results suggest a lack of highly pragmatic trials in OA research. We identify this as a point of opportunity to improve research translation, since optimizing the design and reporting of pragmatic trials can facilitate implementation of evidence-based interventions for OA care.
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Affiliation(s)
| | | | | | | | - Joy C MacDermid
- Faculty of Health Sciences
- Hand and Upper Limb Centre Clinical Research Laboratory, St. Joseph’s Health Centre, London, ON, Canada
| | - Deborah Fitzsimmons
- Faculty of Health Sciences
- School of Nursing and Allied Health, Liverpool John Moores University, Liverpool
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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