December 18, 2019: NIH Collaboratory Shares New Findings and Fresh Insights in 2019

NIH Collaboratory researchers in 2019 continued to generate new knowledge and research methods in pragmatic clinical trials. Their work included insights from the Coordinating Center and Core Working Groups, large-scale analyses of data from the NIH Collaboratory Distributed Research Network, and results and innovative methodological approaches from the NIH Collaboratory Trials.

So far this year, the NIH Collaboratory has produced nearly 3 dozen articles in the peer-reviewed literature, including the primary results of the ABATE Infection trial, confirmation by the TiME trial of the feasibility of embedding large pragmatic trials in clinical care, and more:

NIH Collaboratory Coordinating Center

NIH Collaboratory Distributed Research Network

ABATE Infection NIH Collaboratory Trial

EMBED NIH Collaboratory Trial

PPACT NIH Collaboratory Trial

PRIM-ER NIH Collaboratory Trial

PROVEN NIH Collaboratory Trial

SPOT NIH Collaboratory Trial

STOP CRC NIH Collaboratory Trial

TiME NIH Collaboratory Trial

TSOS NIH Collaboratory Trial

March 13, 2019: PROVEN Publishes Study of Nursing Home Characteristics Associated With Implementation of an Advance Care Planning Video Intervention

The NIH Collaboratory Trial Pragmatic Trial of Video Education in Nursing Homes (PROVEN) is testing the effectiveness of a novel advance care planning (ACP) video education program in 360 nursing homes within 2 large nursing home healthcare systems. The investigators of PROVEN recently published a study that examines the characteristics of nursing homes associated with implementation of the video. They found that lower quality nursing homes (rated 1 star) had lower offer rates than higher quality nursing homes, suggesting that ongoing support might be necessary in these settings, as well as engagement with a local champion.

ACP is a process by which individuals define their future goals and preferences for medical treatment at the end of life and discuss these goals with their family and healthcare providers. ACP is especially important for nursing home residents, who often receive unnecessary care and experience burdensome transitions at the end of life. The ACP intervention in PROVEN is delivered by an onsite champion at the facility—usually a social worker with structured training in how and when to offer and show the ACP videos to residents and families.

 “These results have implications for future pragmatic trials in the NH [nursing home] setting because ongoing engagement between research and NH staff appears crucial for successful integration of interventions into routine clinical practice. Future research is needed to understand how to best engage NHs in implementation and encourage communication between NHs to share pragmatic strategies for improving clinical practice without the support of research staff.”

– Loomer et al. Journal of the American Medical Directors Association

August 23, 2018: PROVEN Team Uses PRECIS-2 to Evaluate Ongoing Trial Implementation

A tool used to rate how the design of a pragmatic clinical trial will influence the real-world applicability of its results can also be used in real time to assess the impact of changes in trial implementation, a recent study published in Trials found.

When designing a pragmatic trial to test the effectiveness of an intervention under "real-world" conditions, researchers use the Pragmatic Explanatory Continuum Indicator Summary-2 (PRECIS-2) to assess how a variety of design features may affect the applicability of trial results for the intended users. A pragmatic trial differs from a traditional "explanatory" trial, which tests the efficacy of an intervention under ideal conditions. PRECIS-2 rates design features on a scale from "explanatory" to "pragmatic" within several domains. The end users of trial results, such as health care systems, may need the results to be more or less "pragmatic" on the explanatory–pragmatic spectrum in order to implement the intervention in their own care delivery settings.

In a novel effort, researchers with the Pragmatic Trial of Video Education in Nursing Homes (PROVEN) used PRECIS-2 during the conduct of the trial to assess the effects of midtrial changes in implementation. PROVEN, an ongoing NIH Collaboratory Trial, is a pragmatic, cluster randomized trial evaluating the effectiveness of video-assisted decision support tools for advance care planning in nursing homes.

In the initial design of PROVEN, design features in the implementation-focused domains of PRECIS-2 were relatively pragmatic, especially in the domain measuring flexibility in the delivery of the intervention. As the trial progressed, adaptations in implementation that were necessary to address challenges in monitoring and protocol adherence led to more explanatory approaches. The investigators concluded that some pragmatic trials, such as those conducted in complex health care systems like nursing homes, "may benefit from a more dynamic approach to implementation which allows for fluidity between pragmatic and explanatory features." PRECIS-2 can be useful in evaluating the impact of midtrial adaptations with these dynamic approaches to trial implementation.

PROVEN is one of the first large-scale pragmatic trials to be conducted in nursing homes. Learn more about PRECIS-2 in the Living Textbook.