title: Clinical Trial Educator program - a novel approach to accelerate enrollment in a phase III International Acute Coronary Syndrome Trial.
abstract: BACKGROUND
  The conduct of current cardiovascular outcome trials requires investigation of thousands of patients at hundreds of investigator sites. Such large trials are clinically and logistically highly demanding and often tend to finish with significant delays, consequently delaying patient access to new medicines.
  
  
  OBJECTIVE
  To address this issue, we designed and implemented a novel approach - a Clinical Trial Educator (CTE) program - to accelerate enrollment in the Thrombin-Receptor Antagonist for Clinical Event Reduction (TRA•CER) trial. This article analyzes the effect of this approach on the study milestones: patient recruitment, site start-up time, and recruitment rate.
  
  
  METHODS
  Scientifically qualified and specifically trained CTEs regularly visited TRA•CER investigator sites in 18 European countries where they trained and educated investigators and site personnel to support them address recruitment challenges. Patient recruitment was assessed in absolute numbers and as recruitment rates, both in relation to CTE site visits.
  
  
  RESULTS
  CTEs performed 2184 visits at 373 European TRA•CER sites (out of 921 global sites). Of sites visited by a CTE, significantly less remained without enrolling any patient than of sites not visited by a CTE (5.9% vs. 15.3%; p < 0.001). Sites visited within 30 days after initiation showed a significantly shortened median time to recruitment of the first patient (28 vs. 59 days with visits ≤30 or >30 days after initiation; p < 0.001). Mean patient recruitment rates were significantly higher at visited than at not-visited sites (1.13 vs. 0.89 patients per site per month, p < 0.001) and significantly increased after the first CTE site visit (from 0.70 to 1.17 patients per site per month; p < 0.001). Finally, there were fewer low-recruiting sites and more high-recruiting sites among the CTE-visited sites compared to the not-visited sites, and the mean recruitment rate at high-recruiting sites visited by CTEs was significantly higher than at high-recruiting sites without CTE visits (2.07 vs. 1.64 patients per site per month; p < 0.01).
  
  
  CONCLUSIONS
  The possibility for selection bias is inherent to this post hoc analysis of a nonrandomized data set. The European focus of the CTE program described here might add some geographical bias. Also, other activities such as investigator meetings conducted in parallel with CTE activities might have partly masked the results of our analysis. Finally, the analysis is limited to recruitment-related parameters, and the aspect of cost-effectiveness has not been quantitatively assessed.
  
  
  CONCLUSIONS
  We found a significant positive association between CTE site visits and the assessed recruitment-related study milestones in the TRA•CER trial, and enrollment finished ahead of plan. We propose that a CTE program could efficiently accelerate enrollment in other clinical trials and therapeutic areas and could contribute to shortening patient access time to novel and potential lifesaving treatments in cardiovascular medicine and beyond.
authors.affiliation: Merck Sharp & Dohme-Chibret AG/Essex Chemie AG, Lucerne, Switzerland.
authors.forename: Brigitte
authors.initials: B
authors.lastname: Kendall
authors.forename: Reto
authors.initials: R
authors.lastname: Städeli
authors.forename: Belinda
authors.initials: B
authors.lastname: Schegg
authors.forename: Martin
authors.initials: M
authors.lastname: Olbrich
authors.forename: Edmond
authors.initials: E
authors.lastname: Chen
authors.forename: Rona
authors.initials: R
authors.lastname: Harmelin-Kadouri
authors.forename: Peter
authors.initials: P
authors.lastname: Aurup
authors.forename: Tilmann
authors.initials: T
authors.lastname: Schwab
authors.forename: Steven K
authors.initials: SK
authors.lastname: Hildemann
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy; D017326:Clinical Trials, Phase III as Topic / Q000379:methods*; D004493:Education; D005060:Europe; D006801:Humans; D007783:Lactones / Q000627:therapeutic use; D015337:Multicenter Studies as Topic; D018579:Patient Selection; D011725:Pyridines / Q000627:therapeutic use; D018179:Receptors, Thrombin / Q000037:antagonists & inhibitors; D012107:Research Design; D018401:Sample Size
chemical_list: D007783:Lactones; D011725:Pyridines; D018179:Receptors, Thrombin; C530299:vorapaxar