Comparative costs and activity from a sample of UK clinical trials units

BackgroundThe costs of medical research are a concern. Clinical Trials Units (CTU) need to better understand reasonable and legitimate variations in the costs of activities.MethodsRepresentatives of ten CTUs and two grant-awarding bodies pooled their experiences in discussions over a year-and-a-half. Five of the CTUs provided estimates of, and written justification for, costs associated with CTU activities required to implement an identical protocol. The protocol described a 5.5 year non-pharmacological RCT conducted at 20 centres. Direct and indirect costs, the number of Full Time Equivalents (FTEs) and the FTEs attracting overheads were compared and qualitative methods (unstructured interviews and thematic analysis) were used to interpret the results. Four members of the group (funding-body representatives or award panel members) reviewed the justification statements for transparency and information content. Separately, 163 activities common to trials were assigned to roles used by nine CTUs; the consistency of role delineation was assessed by Cohen's κ.ResultsMedian full economic cost of CTU activities was £769,637 (range: £661,112 to £1,383,323). Indirect costs varied considerably, accounting for between 15% and 59% (median 35%) of the full economic cost of the grant. Excluding one CTU which used external statisticians, the total number of FTEs ranged from 2.0 to 3.0; total FTEs attracting overheads ranged from 0.3 to 2.0. Variation in directly incurred staff costs depended on whether CTUs: supported particular roles from core funding rather than grants; opted not to cost certain activities into the grant; assigned clerical or data management tasks to research or administrative staff; employed extensive on-site monitoring strategies (also the main source of variation in non-staff costs). Funders preferred written justifications of costs that described both FTEs and indicative tasks for funded roles, with itemised non-staff costs. Consistency in role delineation was fair(κ=0.21-0.40) for statisticians / data managers and poor for other roles (κ<0.20).ConclusionsSome variation in costs is due to factors outside the control of CTUs, such as access to core funding and levels of indirect costs levied by host institutions. Research is needed on strategies to control costs appropriately, especially the implementation of risk-based monitoring strategies

SaFaRI: sacral nerve stimulation versus the FENIX (TM) magnetic sphincter augmentation for adult faecal incontinence: a randomised investigation

Purpose Faecal incontinence is a physically, psychologically and socially disabling condition. NICE guidance (2007) recommends surgical intervention, including sacral nerve stimulation (SNS), after failed conservative therapies. The FENIX™ magnetic sphincter augmentation (MSA) device is a novel continence device consisting of a flexible band of interlinked titanium beads with magnetic cores that is placed around the anal canal to augment anal sphincter tone through passive attraction of the beads. Preliminary studies suggest the FENIX™ MSA is safe, but efficacy data is limited. Rigorous evaluation is required prior to widespread adoption. Method and design The SaFaRI trial is a National Institute of Health Research (NIHR) Health Technology Assessment (HTA)-funded UK multi-site, parallel group, randomised controlled, unblinded trial that will investigate the use of the FENIX™ MSA, as compared to SNS, for adult faecal incontinence resistant to conservative management. Twenty sites across the UK, experienced in the treatment of faecal incontinence, will recruit 350 patients randomised equally to receive either SNS or FENIX™ MSA. Participants will be followed-up at 2 weeks post-surgery and at 6, 12 and 18months post-randomisation. The primary endpoint is success, as defined by device in use and ≥50 % improvement in the Cleveland Clinic Incontinence Score (CCIS) at 18 months post-randomisation. Secondary endpoints include complications, quality of life and cost effectiveness. Discussion SaFaRI will rigorously evaluate a new technology for faecal incontinence, the FENIX™ MSA, allowing its safe and controlled introduction into current clinical practice. These results will inform the future surgical management of adult faecal incontinence

Comparative eff ectiveness of MRI in breast cancer (COMICE) trial: a randomised controlled trial

Summary Background MRI might improve diagnosis of breast cancer, reducing rates of reoperation. We assessed the clinical effi cacy of contrast-enhanced MRI in women with primary breast cancer

Acceptance and Commitment Therapy to support medication decision-making and quality of life in women with breast cancer : protocol for a pilot randomised controlled trial

Background: Adherence to adjuvant endocrine therapy is affected by medication side-effects and associated distress. Previous interventions focused on educating women to enhance adherence have proved minimally effective. We co-designed an Acceptance and Commitment Therapy (ACT) intervention to enhance medication decision-making and quality of life by targeting a broader range of factors, including side-effect management and psychological flexibility. This study aims to establish key trial parameters, assess the acceptability of the intervention and the extent to which it can be delivered with fidelity, and to demonstrate "proof of principle" regarding its efficacy on primary and process outcomes. Methods: The ACTION intervention includes an individual 1:1 ACT session followed by three group sessions involving 8–10 women and two practitioner psychologists. Participants are also provided with access to a website containing evidence-based methods for self-managing side-effects. The ACT sessions were adapted during the COVID-19 pandemic to be remotely delivered via video conferencing software. To evaluate the feasibility and acceptability of this intervention, a multi-site, exploratory, two-arm, individually randomised external pilot trial with a nested qualitative study will be undertaken. Eighty women with early stage breast cancer prescribed adjuvant endocrine therapy will be randomised (1:1) to receive treatment as usual or treatment as usual plus the ACTION intervention. The planned future primary outcome is medication adherence assessed by the ASK-12 measure. Progression to a phase III RCT will be based on criteria related to recruitment and follow-up rates, acceptability to patients, competency and fidelity of delivery, and proof of principle for change in medication adherence. Discussion: This external pilot trial will be used to ascertain the feasibility of undertaking a future phase III RCT to definitively evaluate an ACT-based intervention to support medication taking behaviour and quality of life in women with early stage breast cancer on adjuvant endocrine therapy. Trial registration: ISRCTN: 12027752. Registered 24 December 2020, https://doi.org/10.1186/ISRCTN1202775

Liver resection surgery versus thermal ablation for colorectal LiVer MetAstases (LAVA):study protocol for a randomised controlled trial

Background: Although surgical resection has been considered the only curative option for colorectal liver metastases (CLM), thermal ablation has recently been suggested as an alternative curative treatment. A prospective randomised trial is required to define the efficacy of resection vs ablation for the treatment of colorectal liver metastases. Methods: Design and setting: This is a multicentre, open, randomised controlled non-inferiority trial design with internal pilot and will be performed in tertiary liver centres in UK and The Netherlands. Participants: Eligible patients will be those with colorectal liver metastases at high surgical risk because of their age, co-morbidities or tumour burden and who would be suitable for liver resection or thermal ablation. Intervention: Thermal ablation as per local policy. Control: Surgical liver resection performed as per centre protocol. Co-interventions: Further chemotherapy will be offered to patients as per current practice. Outcomes: Pilot study: Same as main study and in addition patients and clinicians’ acceptability of the trial to assist in optimisation of recruitment. Primary outcome: Disease-free survival (DFS) at two years post randomisation. Secondary outcomes: Overall survival, timing and site of recurrence, additional therapy after treatment failure, quality of life, complications, length of hospital stay, costs, trial acceptability, DFS measured from end of intervention. Follow-up: 24 months from randomisation; five-year follow-up for overall survival. Sample size: 330 patients to demonstrate non-inferiority of thermal ablation. Discussion: This trial will determine the effectiveness and cost-effectiveness of thermal ablation vs surgical resection for high-risk people with colorectal liver metastases, and guide the optimal treatment for these patients

NIHR Liver/Renal Biomarker Programme Final Report: Evaluating the benefits for patients and the NHS of new and existing biological fluid biomarkers in liver and renal disease

Protein biomarkers are naturally occurring substances that can be measured, often in fluids such as blood or urine, and which provide information about a patient and their illness. Different diseases have different biomarkers. When people become ill, changes in biomarker levels may occur before any clinical symptoms or signs become apparent. Measuring biomarkers in blood or urine is simple, safe and may help the doctor diagnose which disease the patient has, determine how severe it is, help choose the best treatment and help detect if the disease is getting worse or better. Unfortunately, for many diseases there are not enough biomarkers that are of proven usefulness in patient care today. New developments in research mean that many more are now being discovered but there is no quick and reliable way to decide which of the markers are good enough to be useful clinically. While our research proposal focusses on diseases of the liver and kidney, in the future it can also serve as the "blueprint" for similar work in other diseases. It is aimed at developing a structure and methods to assess the clinical usefulness of biomarkers as quickly and efficiently as possible. The research is divided into three parallel workstreams : 1. Identification of the best research methods for monitoring disease or treatment with biomarkers - the lack of understanding this has hampered this field so far. 2. The creation of a sample "banking" system for collecting and storing patient samples and relevant clinical data from large numbers of patients. This will allow the immediate testing of potential new biomarkers now and in the future. The best biomarkers would then go on to full trials to see if patients and the NHS would benefit from their use. 3. A clinical trial at multiple hospitals in the UK of three new biomarkers for liver damage (together called the "Enhanced liver fibrosis" or "ELF", test). We will find out if ELF can give early warning of dangerous liver damage (cirrhosis) and therefore reduce the risk of major complications. This trial may radically alter the way in which patients with liver disease can be looked after clinically. This research programme will benefit patients and the NHS by ensuring that biomarkers in the future can be evaluated and introduced more rapidly, improving clinical management for each individual patient and leading to better use of NHS resources