A concept for trial institutions focussing on randomised controlled trials in surgery

Background Although considered the reference standard for generating valid scientific evidence of a treatment's benefits and harms, the number of Randomised Controlled Trials (RCT) comparing surgical techniques remains low. Much effort has been made in order to overcome methodological issues and improve quality of RCTs in surgery. To the present there has been, however, only little emphasis on development and maintenance of institutions for implementation of adequately designed and conducted surgical RCTs. Mehods/Design Description of the developments in surgical RCT infrastructure in Germany between 2001 and 2006. Cross sectional evaluation of completed and ongoing surgical RCTs within the German Surgical Society and the Clinical Study Centre, Department of Surgery, University of Heidelberg. Results Foundation of a national Clinical Trial Centre (CTC) for the organisation of multi-centre RCTs in the surgical setting (Study Center of the German Surgical Society, SDGC). Establishment of a network of CTCs with affiliated Clinical Sites (CSs) to enhance patient recruitment and shorten the duration of RCTs. Since its foundation four surgical RCTs with a total sample size of 1650 patients (1006 of these randomised) have been supervised by the SDGC with 35 CSs involved in patient recruitment. Five further CTCs were set up in 2006. Together with their affiliated CSs a network has been organised providing improved conditions for the conduction of surgical RCTs. Conclusion Improvement of infrastructure substantially facilitates integration of RCTs into routine surgical practice. A network of collaborating CTCs and CSs can provide an adequate infrastructure for the conduction of multi-centre RCTs.


Background
Randomised Controlled Trials (RCT) are considered the reference standard for generating valid scientific evidence on benefits and harms of treatments in surgery [1]. How-ever, the percentage of RCTs dealing with surgical interventions is still low. A Medline analysis revealed that only about 15% of all published RCTs were conducted in the surgical setting [2]. It is estimated that only 24% of surgical therapies are based on the results of RCTs [3].
There are considerable national differences in the extent to which surgical RCTs (sRCTs) are pursued. In the United States the American College of Surgeons Oncology Group (ACOSOG) was founded in 1996 and is funded by the National Cancer Institute in order to increase the quantity and quality of sRCTs [4]. In Europe, the number of RCTs (adjusted for population size) conducted in the United Kingdom and the Netherlands is substantially higher than in most other European countries, with Germany lagging far behind [5]. Furthermore, the number of sRCTs in the leading German surgical journal "Der Chirurg" have decreased since 2000, while the corresponding number of sRCTs in international surgical journals has remained constant [6]. Although the German Science Council already recognised a lack of patient-oriented clinical research in Germany in the early 1990s, major national problems, i.e. lack of funding and a weak infrastructure for the implementation of surgical trials, were still present in 2003 [7]. However, within the last few years much effort has been invested into forming a working national infrastructure in surgical departments and the German Surgical Society (Deutsche Gesellschaft für Chirurgie) in order to establish an environment in which high-quality sRCTs can be performed on a larger scale.
The objective of this article is to describe recent developments in surgical trial infrastructure in Germany providing a sketch of how trial institutions for sRCTs might be organised. It's outline follows a previously proposed structure for reports dealing with quality improvement in health care [8].

The problem
RCTs in surgery comprise several challenges regarding methodology (difficulties with standardisation and blinding), ethics (correct timing of sRCTs, clinical equipoise, and placebo surgery), surgeons (scepticism to randomise patients, lack of methodological expertise and time), and patients (preference for less invasive procedures, reluctance to be randomised to different surgical procedures) [1,9]. Therefore increasing the quantity and quality of sRCTs is a complex task requiring both a working infrastructure and sufficient funding.

Key measures for improvement
A dual concept has been developed consisting of a Clinical Trial Centre (CTC), responsible for planning, conduction (management), and analysis of multi-centre sRCTs and of Clinical Sites (CS), which primarily focus on recruitment and treatment of study patients in accordance with Good Clinical Practice (GCP) guidelines [10]. The effectiveness of this approach can be evaluated quantita-tively at the CTC level according to the number of performed multi-centre sRCTs, the number of recruited CSs, and the foundation of additional CTCs. In addition to these quantitative measures, established processes are evaluated qualitatively (e.g. the extent of collaborations with different scientific institutions and the adherence to the principles of GCP). Similarily, CSs are evaluated by the number and spectrum of conducted trials, the number of included patients, and the extent of cooperations.

Gathering information and strategies for change Clinical Trial Centre (CTC)
The development of a national CTC for multi-centre sRCTs was based on several meetings of the German Surgical Society's Steering Committee and a visit to ACO-SOG. This visit was accompanied by representatives of the German Federal Ministry of Education and Research which constitutes the central national body for institutional grants and regularly announces new programs for the medical sciences. As a result thereof the German Surgical Society commissioned the Department of Surgery at the University of Heidelberg to apply for a grant in 2003 in order to establish the Study Centre of the German Surgical Society [Studienzentrum der Deutschen Gesellschaft für Chirurgie (SDGC)]. This decision was based on the pre-existing facilities for surgical trials and local expertise at the University of Heidelberg, including a well established Institute for Biometrics and a centre for clinical trials (see below). The aim of the SDGC is to provide services to surgeons intending to initiate or participate in multi-centre sRCTs. The tasks of the SDGC include: selection of trial ideas and study development, fund raising, registration of trials, compliance with legal requirements, ethical review management, conduction and analysis of trials, selection, monitoring, and auditing of CSs, quality assurance, education, and publication. An organisational structure was set up for the SDGC consisting of boards and units that involve representatives of the German Surgical Society and the Medical Faculty of the University of Heidelberg [9]. In order to properly address all relevant aspects of sRCTs, an interdisciplinary team (n = 12) consisting of surgeons trained in clinical trials, biometricians, study nurses, clinical research associates, data managers, monitors, and administrative people was formed. Furthermore, collaborations with relevant institutions were initiated, such as with the German Cochrane Centre for systematic reviews and meta-analysis (planning of trials) and the Coordinating Centres for Clinical Trials Network. Trial ideas can be submitted via the SDGC homepage and subsequently run through a fourstep selection process which for approved studies ultimately results in a finalised study protocol. The SDGC prioritises study ideas following the FINER criteria: feasible, interesting, novel, ethical, relevant. A detailed description of the process with further details on study selection and protocol design was published by the SDGC [11].
The SDGC's CSs were formed based on the results of a nationwide survey of surgical departments during which 237 of 1274 departments expressed their willingness to participate in clinical trials.
The German Federal Ministry of Education and Research approved the grant to the SDGC after external peer review and funding started in 2005 for a period of six years. Additional funding was provided by the German Surgical Society and industrial partners (Ethicon, Tyco Healthcare, and Aesculap).

Clinical Sites (CS)
CSs provide access to patient populations. During multicentre surgical trials, the duties of CSs comprise screening of patients for eligibility to be included in ongoing trials based on predefined inclusion criteria, informing and obtaining informed consent of patients, and treatment of patients according to a study protocol and to GCP. The Centre for Clinical Studies [Klinisches Studienzentrum Chirurgie (KSC)] at the Department of Surgery at the University of Heidelberg provides an example of how a CS can be set up [12]. The KSC was already founded in October 2001 with the intention of performing surgical trials in a standardised fashion and to increase the number of patients participating in surgical trials. After the recruitment of professional personnel (two surgeons, three study nurses, and a study secretary), the first patient was recruited into a sRCT in May 2002. Subsequently, a network between the Central Patient Management, responsible for all admissions to the Department of Surgery [13], the local ethics committee, and the hospital administration was established. This network ensures high effi-  [14,15]. The number of CSs recruited and initiated for the SDGC's multi-centre sRCTs has now increased to 35. Two positions were created at the SDGC in order to teach surgical residents the methods of clinical research and epidemiology. In addition, a professional education program for surgeons in trials was successfully established, and the results of the participant evaluation published [16].

Clinical Sites
Since its foundation in 2001, 25 clinical studies were successfully completed at the KSC (five surgical, two observational and 18 pharmaceutical studies). Currently, 24 clinical studies are supervised by the KSC (ten surgical, two observational and 12 pharmaceutical studies). To date, more than 1700 patients have been randomised and treated according to study protocols (Table 2). Five singlecentre sRCTs have been set up, registered, and four out of five study protocols were published (Table 1) [17][18][19][20].
Results for the primary endpoint of three trials (Beger/ Bern, POVATI, PORTAS) will be available in 2008. Table 3 gives an overview of key issues to be considered for organisation of CTCs and CSs based on the knowledge acquired by the SDGC and KSC during the last years. The different mentioned aspects should be addressed via specific Standardized Operating Procedures.

Conclusion
The quantitiy and quality of sRCTs are substantially dependent on a functional trial infrastructure. The developments in Germany demonstrate that the concept of cooperating CTCs and CSs is a promising approach. Surgical departments are able to conduct sRCTs according to GCP guidelines within daily clinical routine, if they set up a CS staffed with at least one study nurse and one study surgeon. Furthermore, multi-centre sRCTs can be performed if collaboration of CTCs and CSs is institutionalised and the relevant scientific organisations are involved. Last but not least funding is an essential factor required for establishment of adequate infrastructure and the implementation of the projects. Consolidation and growth of the established institutions and network supported by sufficient funding will be essential for sustainable increase of sRCTs. In times of limited human recourses and financial constraints international collaborations will be a further step forward in order to enhance multi-centre sRCTs. The established trial infrastructure must not only ensure proper preparation and implementation of sRCTs, but also educate surgeons adequately about the principles of clinical trials.

Competing interests
The author(s) declare that they have no competing interests.