Data and Safety Monitoring During Randomized Controlled Trials of Nursing Interventions
Nancy T. Artinian ▼ Erika Sivarajan Froelicher ▼
Background: Principal investigators have a responsibility to ensure and maintain the
scientific integrity of their research studies and to protect the safety of the partici-
pants. Data and safety monitoring is required for all types of clinical trials, and the
nature and degree of the monitoring must be related to the degree of risk involved. Objectives:
This article aims to define the purpose of a data and safety monitoring
board (DSMB), to describe the functions of a DSMB and distinguish them from the
activities of an institutional review board, and to discuss the development and imple-
Methods: The literature on data and safety monitoring is reviewed, and the process and
key issues are illustrated with examples from the authors’ clinical trial and others. Results: The principal role of the DSMB is to monitor the data from the trial periodically,
to review and assess the performance of its operations, and to make recommenda-
tions based on interim results (e.g., modification of the study protocol, or possible
early termination of the study). Although the roles of a DSMB and institutional reviewboard complement one another, the main focus of their responsibilities is different
What Is Data and Safety
and carried out independently of one another. The members of a DSMB are selected
on the basis of their methodologic, statistical, or clinical expertise. Conclusion: The multiple scientific, ethical, safety, recruitment, intervention, and bud-
getary responsibilities of a principal investigator can be complex. The role of the
DSMB is crucial and offers independent evaluation to ensure participant safety and
Key Words: adverse events ⅐ data and safety monitoring ⅐ institutional review board Nancy T. Artinian, PhD, RN, BC, FAHA, is Professor and Director of Doctoral and Postdoctoral Programs, College of Nurs-ing; and Jillon S. Vander Wal, PhD, is Assistant Professor, Center for HealthResearch, Wayne State University, Detroit,
tific integrity of their studies. On June
Erika Sivarajan Froelicher, RN, PhD, FAAN, is Professor, Department of Physi- ological Nursing, Department of Epidemi-ology & Biostatistics, Schools of Nursingand Medicine, University of California SanNursing Research Nursing Research
Data and Safety Monitoring 415 TABLE 1. Criteria Used to Determine Adverse Events, the Need for Additional Safety Measures, or the Need to Stop the Trial
1. Dropout from one study group is four times greater than the dropout rate from the other group. Attrition from each study group is expected to
2. Less than five persons recruited per month. The monthly target recruitment goal is 16.
3. Unresolved equipment failures greater or equal to 50% of the telemonitoring intervention group. Because telemonitoring is a fairly new
technology, some equipment failures are expected.
4. Adverse health event (death, stroke, myocardial infarction) rates in the telemonitoring intervention group two-fold greater than adverse health
event rates in the usual care group.
5. Level of depression in either group greater than or equal to a score of 27 as measured by the Center for Epidemiologic Studies–Depression
6. For either group, a rise in the mean systolic blood pressure (SBP) greater than or equal to 20 mm Hg or a rise in mean diastolic blood
pressure (DBP) greater than or equal to 10 mm Hg, which is maintained over a 3- to 6-month period.
7. A rise in an individual participant’s SBP to greater than 180 mm Hg or a rise in an individual participant’s DBP to greater than 110 mm Hg.
8. Differential change in systolic and diastolic blood pressure between groups. Functions of a DSMB
tal intervention, and exceptions in eligi-
fied plans for participant retention is an
efforts begin at the time of the first con-
416 Data and Safety Monitoring Nursing Research TABLE 2. Comparison of Data and Safety Monitoring Board (DSMB) and Institutional Review Board
Oversee participant safety; review accumulated
Assess risks and benefits of the proposed
research by reviewing the research protocol
Membership appointments determined by the PI;
Membership determined administratively at
members are approved by the study’s funding
the institution where the IRB is located
Clinicians with expertise with the specific clinical
At least five members with varying backgrounds
problem under investigation, biostatisticians
to promote complete and adequate review of
with expertise in data-monitoring methods,
research activities commonly conducted by the
and possibly medical ethicists; at least
the investigators in the institution; varying
disciplines are represented, including at least
in research design, methodologyand statistics,
one member who is a nonscientist in order to
such as an epidemiologist, who can conduct
appreciate ethical concerns from a variety of
perspectives (Penslar & Porter, 2001).
Evaluate adverse event reports (AERs) within the
Review adverse events and reassess the balance
context of the trial. Evaluate if an observed event
between the risks and the benefits to the
exceeds the expected incidence of that event in a
participants; based on provided information, the
particular population, or if the event is clinically
IRB may reconsider its approval of the study,
meaningful in the context of other medical problems
require modifications to the study, revise the
in the specified population. Provide aggregated data
continuing review time table, or even halt the
summaries to the IRB about the seriousness and
study. An IRB is poorly positioned to evaluate
relatedness of adverse events to the study
AERs owing to lack of information about the
intervention (Morse et al., 2001; National Institutes
clinical meaning of the event in the context of
other medical problems in the specified population.
integrity (Meinert & Tonascia, 1986). A DSMB Versus an IRB
Pocock, & Julian, 1999). Unlike IRBs,
Developing Plans for Data and Safety Monitoring
affiliated (Penslar & Porter, 2001). An
ducting the research ethically (Burns &
that research activities are ethical, its
Data and Safety Monitoring 417
setting potential benefit (Brass, 2001).
start of a trial, specifies a limit for the
groups (Meinert & Tonascia, 1986). Meetings of the DSMB DSMB Membership
their specific methodologic, statistical,
resented expertise related to statistics,
exist (O’Brien & Fleming, 1979).
ficult “stopping rule” decisions. Not
of clear evidence for a beneficial effect
also must be above suspicion of bias. Stopping A Trial
institutional Phase 3 studies (i.e., stud-
418 Data and Safety Monitoring Nursing Research
originally planned termination date.
an angiotensin-converting-enzymeinhibitor, ramipril, on cardiovascular
Accepted for publication May 10, 2004.
events in high-risk patients. New Eng-land Journal of Medicine, 342(3), 145-
DSMB Reports Preparation of this manuscript was partiallysupported by the National Institute of Nurs-ing Research and National Center on Minor-ity Health and Health Disparities/NIH Grant
must report their conclusions to IRBs. Human Research Report, 14(10), 3. Corresponding author: Nancy T. Artinian,
Meinert, C. L., & Tonascia, S. (1986). PhD, RN, BC, FAHA, College of Nursing,Wayne State University, 5557 Cass Avenue,
monitoring. In C. L. Meinert & S.
Tonascia (Eds.), Clinical trials: Design,
such as “continue trial without modifi-
conduct, and analysis (pp. 208-216).
cation,” “continue trial with specific
Moody, L. E., & McMillan, S. (2002).
tion,” “stop the study due to the fol-
lowing safety concerns . . . ,” and “stop
Heart disease and stroke statistics—
ized clinical trials. Nursing Research,
ping rule for efficacy.” In a report from
Morse, M. A., Califf, R. M., & Sugarman,
Armstrong, P. W., & Furberg, C. D.
safety during clinical research. JAMA,
constitution. Circulation, 91(3), 901-
National Institutes of Arthritis and Mus-
culoskeletal and Skin Diseases (2003). Generic monitoring plan for trials
tained at each follow-up date (i.e., 3, 6,
requiring a data and safety monitoring
a general clinical research center. Jour-board. Retrieved March 6, 2003, from
nal of Investigative Medicine, 49(6),
Burns, N., & Grove, S. K. (2001). Ethics
National Institutes of Health.AQ (1998).
and research. In N. Burns & S. K. NIH Policy for Data Safety Monitor-
Grove (Eds.), The practice of nursinging. Retrieved February 11, 2003, from
research (pp. 191-222). Philadelphia:
DeMets, D. L., Pocock, S. J., & Julian, D.
in monitoring of clinical trials. Lancet,
8).AQ Data and safety monitoring exam-ple plans. Retrieved March 12, 2004
O’Brien, P. C., & Fleming, T. R. (1979). A
C. D. Furberg, & D. L. DeMets (Eds.),
Fundamentals of clinical trials (pp. 246-
trials. Biometrics, 35(3), 549-556.
Penslar, R. L., & Porter, J. P. (2001, June
Froelicher, E. S. (1996). Tracing patients
21). IRB Guidebook. Retrieved March 5,
St. Jude Children’s Hospital Cancer Cen-
Froelicher, E. S., Miller, N. H., Buzaitis,
A., Pfenninger, P., Misuraco, A., Jordan,
Whitehead, J. (1999). On being the statis-
sion and/or social isolation. Journal of
Board. Statistics in Medicine, 18(24),
Cardiopulmonary Rehabilitation, 23(4),
Herkennen en hanteren van hersenschade in de werksituatie M a rc o Ve rs te g e n , J a n L a n s e r, H e i lw i n e B a k ke r Medewerkers van tweede- en derdelijnszorgin-van hersenschade tijdig te onderkennen, takenstellingen, zoals Balans & Impuls en de Geheu-en werksituatie aan te kunnen passen aan de ver-genpoli van het Rijnlandziekenhuis, worden dik-minderde mogelijkheden, en
Mu-Tea (Macrobiotic Herbal Beverage) MUSO's Mu-tea is made from herbs, most of which are grown in China. Macrobiotic founder, George Ohsawa was the first to blend them into effective mixtures for various diseases. The herbs used in Mu-tea are selected for only the highest quality and maximal effectiveness. Great care is taken to bringout and maintain the origi