Table 1 Overview of ZQOL study challenges, solutions and implications

1) Identification of centres willing/able to participate in the study

• Identifying centres with interest/capacity to participate in research and the correct people to discuss participation with proved difficult via conventional means (unsolicited mail/email).

• Limitations in dedicating time or resources to external research projects due to clinical workloads and lack of designated support staff were common reasons for non-participation cited by centres. Levels of remuneration provided to centres for participation in the study were considered insufficient by some centres.

• Availability of NHS staff participating in research having completed Good Clinical Practice (GCP) training.

• The ZQOL study was accepted into the National Institute for Health Research Clinical Research Network (NIHR CRN) portfolio. NIHR were able to offer wide range of support services including:

o Access to existing networks of centres with interests in participating in research.

o Provision of support to centres interesting in participating in research.

o Exploring centre eligibility for additional remuneration for participation in NIHR CRN-approved studies.

o Delivering GCP training to centres interesting in participating in studies.

• Experiences indicate the need for greater links between commissioners of research and primary/secondary care centres.

• A refocusing of targets for primary care centres, to provide staff with opportunities and incentives for partaking in research is needed.

• Current R&D approval process makes no concessions for non-interventional research. R&D requirements should be proportionate to the risks associated with patient participation in such studies.

2) Obtaining Ethics and Research & Development (R&D) Management Approval

• Information and documentation required to support R&D applications was a barrier to participation for a number of centres.

• Significant variation in timelines for R&D approval at a local and regional level (i.e. England, Scotland, Wales & Northern Ireland) led to significant delays in the study.

• R&D approval process requires that extensive tri-partite agreements between the study sponsor, co-ordinating CRO and R&D department be agreed and signed. However, there is no standard template available for such agreements.

• ZQOL study organisers implemented a number of practical solutions including:

o Minimising the number of R&D approvals by seeking participation of clusters of centres in the same NHS trust.

o Implemented a staged study roll-out such that R&D applications for key centres were prioritised and R&D applications could occur in parallel to patient recruitment.

• NIHR CRN can also provide assistance:

o As a NIHR-CRN portfolio adopted study, more likely to be considered for priority review by R&D depts.

o NIHR CRN local research network teams are able to offer support and guidance to co-ordinating CROs throughout England.

• Current R&D approval process makes no concessions for non-interventional research. R&D requirements should be proportionate to the risks associated with patient participation in such studies.

• A move to standardise R&D approval process across NHS trusts in England would reduce burden (and barriers) to research for study organisers and NHS staff interested in participating in research.

3) Recruitment of Study Participants

• Recruitment of HZ patients in primary care was slower than envisaged, a likely result of practical and organisational factors:

o As an acute condition, HZ patients had to be recruited on initial presentation to physicians and did not allow searches of eligible participants via patient medical records.

o At the time of the study there will only limited opportunities for notifications and reminders to be incorporated into electronic-record systems on presentation of incident cases.

• Lack of unique identifiers or codes in electronic-record systems made it difficult to identify PHN patients for participation in the ZQOL study.

• To ensure that study recruitment quotas were met, additional centres were recruited for participation in the study and study timelines were extended.

• NIHR CRN local research networks and the co-ordinating CRO were in regular contact with centre staff so to ensure to provide support where needed.

• Standardisation of medical record keeping and greater integration of record and monitoring systems would be to the benefit of facilitating real-world research.

• Centres having systems in place to confirm the feasibility of recruitment numbers and having opportunity to work alongside study organisers could facilitate the development of study inclusion/exclusion criteria that are less restrictive to recruitment in real-world practice.