In a new article in eGems, the NIH Health Care Systems Research Collaboratory’s Patient-Reported Outcomes (PRO) Core gathered first-hand experiences on the incorporation of PROs for both care and research. The Core uses case studies from seven programs to present practical approaches for initiating and implementing PROs. The article includes tips on instrument selection, methods for integrating PRO collection into clinical workflow, consideration for user experience, and methods to monitor and assess data quality.
A new funding opportunity announcement from the NIH solicits applications to support Demonstration Projects that include an efficient, large-scale pragmatic clinical trial. Trials must be conducted across two or more health care systems (HCS) and must be conducted as part of the NIH HCS Research Collaboratory supported through the NIH Common Fund. Awards made through this FOA will initially support a one-year milestone-driven planning phase (UG3), with possible rapid transition to the second implementation phase (UH3) for a pragmatic trial Demonstration Project.
The NIH Collaboratory Demonstration Project, Lumbar Imaging with Reporting of Epidemiology (LIRE), has completed enrollment as of September 30, 2016. LIRE is a pragmatic, cluster-randomized trial testing the effectiveness of inserting epidemiologic benchmarks into lumbar spine imaging reports for reducing subsequent tests and treatments for back pain. Given the rate of age-related, incidental imaging findings in individuals without back pain, many follow-up interventions for back pain based on imaging results are unnecessary. With back pain as one of the most common reasons for doctor visits, this inexpensive intervention has the potential for a large public health impact. The trial will continue to follow subjects for up to 2 years after enrollment using data from the electronic health record, but no new subjects will be enrolled.
Congratulations to the LIRE study team on this important milestone!
The ABATE Infection trial, an NIH Collaboratory project led by Dr. Susan Huang, is featured in the September 12 Health section of the Wall Street Journal. The article describes several studies aimed at preventing the hospital-associated infection MRSA (methicillin-resistant Staphylococcus aureus).
In the Reduce MRSA trial, published in 2013, Dr. Huang’s team demonstrated that treating ICU patients with a germ-fighting soap plus a nasal antibiotic ointment, an approach called “universal decolonization,” was superior to standard approaches in preventing MRSA infections. The ABATE Infection trial examines similar approaches to decolonization for all patients in non–critical care medical and surgical units, comparing the use of an antiseptic bath and nasal ointment to standard bathing and showering. More than 1 million showers and baths were taken over the course of the study, which has now completed enrollment. Data from ABATE are currently being analyzed, with the results expected to inform whether this strategy is effective in reducing hospital-associated infections.
“These are preventable infections and we should be able to drive them down to zero.” Susan Huang, MD
The NIH Collaboratory has developed a tool to assist authors in the complete and transparent reporting of their pragmatic clinical trials (PCTs). In the PCT Reporting Template, users will find descriptions of reporting elements based on CONSORT guidance as well as on expertise from the NIH Collaboratory Demonstration Projects and Core working groups.
Particularly relevant to PCTs are recommendations on how to report the use of data from electronic health records. Other elements of importance to PCTs include reporting wider stakeholder engagement, monitoring for unanticipated changes in study arms, and specific approaches to human subjects protection. The template contains numerous links to online material in the Living Textbook, CONSORT, and the Pragmatic–Explanatory Continuum Indicator Summary tool known as PRECIS-2.
This resource is intended to assist authors in developing primary journal publications. It will be updated over time as new best practices emerge for the transparent reporting of PCTs.
Please note: this document opens as an Adobe PDF. If you do not have software that can open a PDF, click here to download a free version of Adobe Acrobat Reader.
This work was supported by a cooperative agreement (U54 AT007748) from the NIH Common Fund for the NIH Health Care Systems Research Collaboratory. The views presented in this document are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.
Originally published on September 1, 2016.
Questions or comments can be submitted via email. Please add “Living Textbook” to the Subject line of the email.
The authors elaborate on four required components of the framework:
Searchable libraries of explicitly defined phenotype definitions
Knowledge bases with information and methods
Tools to identify, evaluate, and implement existing phenotype definitions
Motivated users and stakeholders
Read the entire eGEMs open access publication here. eGEMs (Generating Evidence & Methods to improve patient outcomes), a product of AcademyHealth’s Electronic Data Methods (EDM) Forum, is a peer-reviewed, open access journal that seeks to accelerate research and quality improvement using electronic health data.
Related resources:You can find extensive information on computable phenotypes in the Living Textbookchapter and in Tools for Research.
In the systematic review, the researchers found that imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, and these findings increase with age. Thus, many degenerative features found on spine imaging are likely part of normal aging. Given that advanced imaging is increasingly used in the evaluation of patients with lower back pain, knowing the prevalence of degenerative findings in asymptomatic individuals can help clinicians and patients when interpreting imaging findings.
The LIRE pragmatic trial is testing the insertion of these epidemiologic benchmarks into lumbar spine imaging reports with the goal of reducing subsequent tests and treatments, including MRI and CT, opioid prescriptions, spinal injections, or surgery.
On Tuesday, May 10, 2016, the NIH Collaboratory invites you to view a public webcast of the workshop, Ethical and Regulatory Issues of Pragmatic Clinical Trials.
This workshop will include several topics from a series of articles discussing regulatory and ethical issues related to the conduct of pragmatic clinical trials. Panelists from the NIH Collaboratory pragmatic trial Demonstration Projects, along with experts in the areas of informed consent, vulnerable populations, IRBs, data monitoring committees, and privacy issues, will participate in moderated discussion using case examples from the NIH Collaboratory.
In a recent post on the FDA’s “FDA Voice” blog, Associate Deputy Commissioner Rachel Sherman and Commissioner Robert Califf describe how to overcome barriers to data sharing and create a successful national system for medical evidence generation (or “EvGen”). To foster new approaches for creating clinical evidence the authors suggest 3 principles:
“1. There must be a common approach to how data is presented, reported and analyzed and strict methods for ensuring patient privacy and data security.
2. Rules of engagement must be transparent and developed through a process that builds consensus across the relevant ecosystem and its stakeholders.
3. To ensure support across a diverse ecosystem that often includes competing priorities and incentives, the system’s output must be intended for the public good and be readily accessible to all stakeholders.”
Drs. Sherman and Califf point to substantial pioneering work being done in secondary use of data, in which data collected for clinical care are “secondarily” used for research, including projects currently underway through the NIH Collaboratory, PCORnet, and other initiatives and networks. The experience gained from these groundbreaking efforts should provide a foundation for a national system for evidence generation.
The Active Bathing to Eliminate (ABATE) Infection trial (ClinicalTrials.gov #NCT02063867) has completed its intervention phase—the first NIH Health Care Systems Research Collaboratory UH3 Demonstration Project to reach this major milestone. The large-scale, cluster-randomized pragmatic clinical trial (PCT) was designed to assess an approach for reducing multidrug-resistant organisms and hospital-associated infections (HAIs) in nearly 200 non-critical care hospital units affiliated with Hospital Corporation of America (HCA) across the United States.
The ABATE study is led by principal investigator Dr. Susan Huang of the University of California, Irvine, who stated “We are elated to reach the successful completion of the trial thanks to an incredible investigative team at HCA, Harvard Pilgrim Health Care, Rush University, the University of Massachusetts Amherst, and UC Irvine. We look forward to what the trial data will tell us and hope that we can continue to find effective ways to protect patients from infection.”
In the ABATE study, patients hospitalized in non-critical care units were bathed either according to the hospital unit’s usual care procedures (the control group) or bathed with the topical antibacterial agent chlorhexidine (plus nasal administration of the antibiotic mupirocin for those patients who were colonized or infected with, or had a history of methicillin-resistant Staphylococcus aureus [MRSA] [the intervention group]). The study investigators will compare the number of unit-attributable, multidrug-resistant organisms in clinical cultures between the study arms; these organisms include vancomycin-resistant enterococci (VRE), MRSA, and gram-negative bacteria. In addition, the investigators will compare the number of unit-attributable infections in the bloodstream and urinary tract (all pathogens) and Clostridium difficile infections. Cultures were collected at baseline and post intervention and will be assessed to determine whether resistance emerged to decolonization products.
“We are elated to reach the successful completion of the trial thanks to an incredible investigative team at HCA, Harvard Pilgrim Health Care, Rush University, the University of Massachusetts Amherst, and UC Irvine.We look forward to what the trial data will tell us and hope that we can continue to find effective ways to protect patients from infection.”
Healthcare-associated infections caused by common bacteria, including MRSA and VRE, are a leading cause of preventable illness and death in the United States and are associated with upward of $6.5 billion in annual healthcare costs. Although these bacteria normally live on the skin or in the nose, under certain circumstances they can cause serious or even life-threatening infections. Hospitalized patients who are ill or who have weakened immune systems are especially at risk for such infections. Because these pathogens are resistant to many antibiotics, they can be difficult to treat.
In intensive care units (ICUs), reducing the amount of such bacteria (a process referred to as decolonization) by treating patients’ skin with chlorhexidine and their noses with mupirocin ointment has been shown to reduce MRSA infections and all-cause bacteremias. However, relatively little is known about the effects of decolonization in hospital settings outside of critical care units, although this is where the majority of such infections occur. The ABATE trial, in contrast, is testing its bathing and decolonization strategy in adult medical, surgical, oncology, and step-down units (pediatric, psychology, peri-partum, and bone marrow transplantation units were excluded).
Over the course of the study, more than a million showers and baths were taken, and all sites have completed the intervention. The next steps for the ABATE investigators are to finish strain collection over the coming weeks, and then clean, validate, and analyze the data over the coming months.