数据采集和管理(说明:数据采集和管理由两部分组成,一为病例记录表(Case Record Form, CRF),二为电子采集和管理系统(Electronic Data Capture, EDC),如ResMan即为一种基于互联网的EDC:
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由本课题组负责人实施对本项目的数据管理。
1.1定义原始数据
(1) 病例报告表填写的所有原始记录的内容以及依据此表产生的电子病例报告表所记录的所有原始记录内容。
(2)化验检查及其他检查项目报告表的所有原始数据。
1.2 数据记录
(1)研究者填写临床试验记录要求:及时、准确、完整、规范、真实;
(2)全部病例均按方案规定,认真书写病历和填写病例报告表,所有项目均需填写,不得空项、漏项(无记录的空格划斜线);
(3)病例报告表作为原始记录,做任何更正时只能划线,旁注修改后的数据,说明理由,并与参加临床试验的医师和研究者签名并注明日期,不得涂搽,覆盖原始记录;
(4)化验单齐全并粘贴在病例报告表上,病例报告表记录的数据要与病历及原始检验报告核对无误;
(5)对显著偏高或临床可接受范围以外的数据(实验室检查项目超过正常值的20%)需加以核实,由参加临床试验的医师做必要的说明;
(6)每一位受试者观察疗程结束后,研究者应在1周内将病例报告表及病历交本单位主要研究者审核、签名。
1.3数据核查
监察员在试验过程中要核查研究者是否遵循试验方案,定期去各调查现场检查受试者的知情同意及筛选纳入情况;
(1)确认所有病例报告表填写及时、正确,并与原始资料真实、一致;所有错误或遗漏均以改正或注明,经研究者签名并注明日期;
(2)核实入选受试者的退出须在病例报告表中予以说明;确认所有不良事件均应记录在案,严重不良事件在规定时间内做出报告并记录在案。
1.4数据录入及分析
(1)建立数据库:根据病例报告表的项目,采用计算机软件建立相应的录入程序,并设定录入时的逻辑审查限定条件,对数据库进行试运行,建立本试验专用的数据库系统;
(2)录入前再次核查:对病例报告表的进一步检查,已经审核声明签字的病例报告表交数据管理员,数据管理员对日期、入组标准、排除标准、缺失值等进行检查,如有疑问,可填写疑问表返回监察员,由研究者对疑问表中的问题进行书面解答并签名,交回数据管理员,疑问表应妥善保管;
(3)数据录入:对数据录入人员培训后进行数据录入,每一份病例报告表采用双份录入法,由两人独立完成;
(4)数据的审核:逐项查对数据录入与病例报告表结果值的一致性,有不一致的地方进行更正,确保数据库的数据与病例报告表上中的结果一致;
(5)数据锁定:除进行上述的数据审核外,还要由主要研究者、统计人员、数据管理员和申办者共同进一步讨论和确认研究方案中的主要内容和统计分析计划书。确认全部数据均以录入数据库,全部疑问均已解决,分析人群已定义并作出判断后锁定数据。
(6)数据处理:由专业统计分析人员进行统计分析。
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Data collection and Management (A standard data collection and management system include a CRF and an electronic data capture:
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The person in charge of this research group implements the data management of this project.
1.1 Define the original data
(1) The contents of all original records filled in the case report form and the contents of all original records recorded in the electronic case report form generated based on this form.
(2) All the original data in the report form of laboratory inspection and other inspection items.
1.2 Data recording
(1) The requirements for investigators to fill in clinical trial records: timely, accurate, complete, standardized, and true;
(2) For all cases, carefully write medical records and fill in the case report form in accordance with the plan. All items must be filled in, and no blank or missing items (unrecorded spaces are slashed);
(3) The case report form is used as the original record. When making any corrections, only a line can be made, and the revised data should be noted along with the reason, and it should be signed and dated with the physicians and researchers participating in the clinical trial. It should not be painted or overwritten. Original record
(4) The laboratory test form is complete and pasted on the case report form. The data recorded in the case report form should be checked with the medical records and original inspection report;
(5) Data that is significantly higher or outside the clinically acceptable range (laboratory inspection items exceeding 20% ??of the normal value) need to be verified, and the physician participating in the clinical trial shall make the necessary explanation;
(6) After each subject's observation course is over, the investigator should submit the case report and medical records to the main investigator of the unit for review and signature within one week.
1.3 Data verification
During the trial process, the inspector shall check whether the investigator is following the trial protocol, and regularly go to each survey site to check the subjects’ informed consent and screening and inclusion status;
(1) Confirm that all case report forms are filled in time and correctly, and are true and consistent with the original information; all errors or omissions are corrected or indicated, and signed and dated by the investigator;
(2) Verify that the withdrawal of selected subjects must be explained in the case report form; confirm that all adverse events should be recorded, and that serious adverse events should be reported and recorded within the specified time.
1.4 Data entry and analysis
(1) Establish a database: According to the items in the case report form, use computer software to establish the corresponding entry procedure, and set the logical review limit conditions during entry, conduct a trial operation on the database, and establish a dedicated database system for this test;
(2) Check again before entry: For further inspection of the case report form, the case report form that has been reviewed and signed is submitted to the data administrator, who will check the date, entry criteria, exclusion criteria, missing values, etc., if any If you have any questions, you can fill out the question form and return it to the inspector. The researcher will answer and sign the questions in the question form in writing, and return it to the data manager. The question form should be properly kept;
(3) Data entry: After training the data entry personnel, enter the data. Each case report form adopts the double entry method and is completed by two persons independently;
(4) Data review: check the consistency of the data entry and the result value of the case report form item by item, correct any inconsistencies, and ensure that the data in the database is consistent with the results on the case report form;
(5) Data locking: In addition to the above-mentioned data review, the main researchers, statisticians, data administrators, and sponsors should further discuss and confirm the main content and statistical analysis plan of the research plan. Confirm that all data are entered into the database, all questions have been resolved, the analysis population has been defined and the data will be locked after making a judgment.
(6) Data processing: statistical analysis by professional statistical analysts.
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