Risk-adapted monitoring is not inferior to extensive on-site monitoring: Results of the ADAMON cluster-randomised study

• Published in: Clinical trials (London, England) England), 2017-12, Vol.14 (6), p.584-596
• Main Authors: Brosteanu, Oana, Schwarz, Gabriele, Houben, Peggy, Paulus, Ursula, Strenge-Hesse, Anke, Zettelmeyer, Ulrike, Schneider, Anja, Hasenclever, Dirk
• Format: Article
• Language: English
• Subjects: Biomedical Research - standards; Clinical medicine; Clinical Protocols; Clinical trials; Clinical Trials as Topic - standards; Clinical Trials as Topic - statistics & numerical data; Clinical Trials Data Monitoring Committees; Cluster Analysis; Clusters; Confidence intervals; Data Interpretation, Statistical; Data Management and Trial Conduct; Design defects; Humans; Life cycle analysis; Logistic Models; Medical research; Monitoring; Onsite; Patients; Prospective Studies; Quality Control; Quality management; Randomization; Regression analysis; Risk; Risk Assessment - standards; Statistical analysis
• ISSN: 1740-7745; 1740-7753
• DOI: 10.1177/1740774517724165

Background According to Good Clinical Practice, clinical trials must protect rights and safety of patients and make sure that the trial results are valid and interpretable. Monitoring on-site has an important role in achieving these objectives; it controls trial conduct at trial sites and informs the sponsor on systematic problems. In the past, extensive on-site monitoring with a particular focus on formal source data verification often lost sight of systematic problems in study procedures that endanger Good Clinical Practice objectives. ADAMON is a prospective, stratified, cluster-randomised, controlled study comparing extensive on-site monitoring with risk-adapted monitoring according to a previously published approach. Methods In all, 213 sites from 11 academic trials were cluster-randomised between extensive on-site monitoring (104) and risk-adapted monitoring (109). Independent post-trial audits using structured manuals were performed to determine the frequency of major Good Clinical Practice findings at the patient level. The primary outcome measure is the proportion of audited patients with at least one major audit finding. Analysis relies on logistic regression incorporating trial and monitoring arm as fixed effects and site as random effect. The hypothesis was that risk-adapted monitoring is non-inferior to extensive on-site monitoring with a non-inferiority margin of 0.60 (logit scale). Results Average number of monitoring visits and time spent on-site was 2.1 and 2.7 times higher in extensive on-site monitoring than in risk-adapted monitoring, respectively. A total of 156 (extensive on-site monitoring: 76; risk-adapted monitoring: 80) sites were audited. In 996 of 1618 audited patients, a total of 2456 major audit findings were documented. Depending on the trial, findings were identified in 18%–99% of the audited patients, with no marked monitoring effect in any of the trials. The estimated monitoring effect is −0.04 on the logit scale with two-sided 95% confidence interval (−0.40; 0.33), demonstrating that risk-adapted monitoring is non-inferior to extensive on-site monitoring. At most, extensive on-site monitoring could reduce the frequency of major Good Clinical Practice findings by 8.2% compared with risk-adapted monitoring. Conclusion Compared with risk-adapted monitoring, the potential benefit of extensive on-site monitoring is small relative to overall finding rates, although risk-adapted monitoring requires less than 50% of extensive on-