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Triggered or routine site monitoring visits for randomised controlled trials: results of TEMPER, a prospective, matched-pair study

BACKGROUND/AIMS: In multi-site clinical trials, where trial data and conduct are scrutinised centrally with pre-specified triggers for visits to sites, targeted monitoring may be an efficient way to prioritise on-site monitoring. This approach is widely used in academic trials, but has never been fo...

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Autores principales: Stenning, Sally P, Cragg, William J, Joffe, Nicola, Diaz-Montana, Carlos, Choudhury, Rahela, Sydes, Matthew R, Meredith, Sarah
Formato: Online Artículo Texto
Lenguaje:English
Publicado: SAGE Publications 2018
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6236642/
https://www.ncbi.nlm.nih.gov/pubmed/30132361
http://dx.doi.org/10.1177/1740774518793379
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author Stenning, Sally P
Cragg, William J
Joffe, Nicola
Diaz-Montana, Carlos
Choudhury, Rahela
Sydes, Matthew R
Meredith, Sarah
author_facet Stenning, Sally P
Cragg, William J
Joffe, Nicola
Diaz-Montana, Carlos
Choudhury, Rahela
Sydes, Matthew R
Meredith, Sarah
author_sort Stenning, Sally P
collection PubMed
description BACKGROUND/AIMS: In multi-site clinical trials, where trial data and conduct are scrutinised centrally with pre-specified triggers for visits to sites, targeted monitoring may be an efficient way to prioritise on-site monitoring. This approach is widely used in academic trials, but has never been formally evaluated. METHODS: TEMPER assessed the ability of targeted monitoring, as used in three ongoing phase III randomised multi-site oncology trials, to distinguish sites at which higher and lower rates of protocol and/or Good Clinical Practice violations would be found during site visits. Using a prospective, matched-pair design, sites that had been prioritised for visits after having activated ‘triggers’ were matched with a control (‘untriggered’) site, which would not usually have been visited at that time. The paired sites were visited within 4 weeks of each other, and visit findings are recorded and categorised according to the seriousness of the deviation. The primary outcome measure was the proportion of sites with ≥1 ‘Major’ or ‘Critical’ finding not previously identified centrally. The study was powered to detect an absolute difference of ≥30% between triggered and untriggered visits. A sensitivity analysis, recommended by the study’s blinded endpoint review committee, excluded findings related to re-consent. Additional analyses assessed the prognostic value of individual triggers and data from pre-visit questionnaires completed by site and trials unit staff. RESULTS: In total, 42 matched pairs of visits took place between 2013 and 2016. In the primary analysis, 88.1% of triggered visits had ≥1 new Major/Critical finding, compared to 81.0% of untriggered visits, an absolute difference of 7.1% (95% confidence interval −8.3%, +22.5%; p = 0.365). When re-consent findings were excluded, these figures reduced to 85.7% versus 59.5%, (difference = 26.2%, 95% confidence interval 8.0%, 44.4%; p = 0.007). Individual triggers had modest prognostic value but knowledge of the trial-related activities carried out by site staff may be useful. CONCLUSION: Triggered monitoring approaches, as used in these trials, were not sufficiently discriminatory. The rate of Major and Critical findings was higher than anticipated, but the majority related to consent and re-consent with no indication of systemic problems that would impact trial-wide safety issues or integrity of the results in any of the three trials. Sensitivity analyses suggest triggered monitoring may be of potential use, but needs improvement and investigation of further central monitoring triggers is warranted. TEMPER highlights the need to question and evaluate methods in trial conduct, and should inform further developments in this area.
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spelling pubmed-62366422018-12-03 Triggered or routine site monitoring visits for randomised controlled trials: results of TEMPER, a prospective, matched-pair study Stenning, Sally P Cragg, William J Joffe, Nicola Diaz-Montana, Carlos Choudhury, Rahela Sydes, Matthew R Meredith, Sarah Clin Trials Articles BACKGROUND/AIMS: In multi-site clinical trials, where trial data and conduct are scrutinised centrally with pre-specified triggers for visits to sites, targeted monitoring may be an efficient way to prioritise on-site monitoring. This approach is widely used in academic trials, but has never been formally evaluated. METHODS: TEMPER assessed the ability of targeted monitoring, as used in three ongoing phase III randomised multi-site oncology trials, to distinguish sites at which higher and lower rates of protocol and/or Good Clinical Practice violations would be found during site visits. Using a prospective, matched-pair design, sites that had been prioritised for visits after having activated ‘triggers’ were matched with a control (‘untriggered’) site, which would not usually have been visited at that time. The paired sites were visited within 4 weeks of each other, and visit findings are recorded and categorised according to the seriousness of the deviation. The primary outcome measure was the proportion of sites with ≥1 ‘Major’ or ‘Critical’ finding not previously identified centrally. The study was powered to detect an absolute difference of ≥30% between triggered and untriggered visits. A sensitivity analysis, recommended by the study’s blinded endpoint review committee, excluded findings related to re-consent. Additional analyses assessed the prognostic value of individual triggers and data from pre-visit questionnaires completed by site and trials unit staff. RESULTS: In total, 42 matched pairs of visits took place between 2013 and 2016. In the primary analysis, 88.1% of triggered visits had ≥1 new Major/Critical finding, compared to 81.0% of untriggered visits, an absolute difference of 7.1% (95% confidence interval −8.3%, +22.5%; p = 0.365). When re-consent findings were excluded, these figures reduced to 85.7% versus 59.5%, (difference = 26.2%, 95% confidence interval 8.0%, 44.4%; p = 0.007). Individual triggers had modest prognostic value but knowledge of the trial-related activities carried out by site staff may be useful. CONCLUSION: Triggered monitoring approaches, as used in these trials, were not sufficiently discriminatory. The rate of Major and Critical findings was higher than anticipated, but the majority related to consent and re-consent with no indication of systemic problems that would impact trial-wide safety issues or integrity of the results in any of the three trials. Sensitivity analyses suggest triggered monitoring may be of potential use, but needs improvement and investigation of further central monitoring triggers is warranted. TEMPER highlights the need to question and evaluate methods in trial conduct, and should inform further developments in this area. SAGE Publications 2018-08-22 2018-12 /pmc/articles/PMC6236642/ /pubmed/30132361 http://dx.doi.org/10.1177/1740774518793379 Text en © The Author(s) 2018 http://creativecommons.org/licenses/by/4.0/ This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
spellingShingle Articles
Stenning, Sally P
Cragg, William J
Joffe, Nicola
Diaz-Montana, Carlos
Choudhury, Rahela
Sydes, Matthew R
Meredith, Sarah
Triggered or routine site monitoring visits for randomised controlled trials: results of TEMPER, a prospective, matched-pair study
title Triggered or routine site monitoring visits for randomised controlled trials: results of TEMPER, a prospective, matched-pair study
title_full Triggered or routine site monitoring visits for randomised controlled trials: results of TEMPER, a prospective, matched-pair study
title_fullStr Triggered or routine site monitoring visits for randomised controlled trials: results of TEMPER, a prospective, matched-pair study
title_full_unstemmed Triggered or routine site monitoring visits for randomised controlled trials: results of TEMPER, a prospective, matched-pair study
title_short Triggered or routine site monitoring visits for randomised controlled trials: results of TEMPER, a prospective, matched-pair study
title_sort triggered or routine site monitoring visits for randomised controlled trials: results of temper, a prospective, matched-pair study
topic Articles
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6236642/
https://www.ncbi.nlm.nih.gov/pubmed/30132361
http://dx.doi.org/10.1177/1740774518793379
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