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.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。
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。
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。
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 project data management is implemented by the person in charge of this project group.
1. define the original data
(1) The contents of all original records filled in the case report form and all the original records recorded in the electronic case report form generated according to this form.
(2) All raw data from the report form of laboratory inspection and other inspection items.
2. data record
(1) The researchers fill in the requirements of clinical trial records: timely, accurate, complete, standardized and true;
(2) All cases shall be carefully written and filled in case report form according to the plan. All items shall be filled in, and no empty items or omissions shall be allowed (blank without record shall be slashed);
(3) The case report form is used as the original record. When making any correction, only the line can be crossed, the modified data can be annotated, the reasons are explained, and the doctor and researcher participating in the clinical trial shall sign and date the case report form, and shall not be applied to cover the original record;
(4) The test list is complete and pasted on the case report form. The data recorded in the case report form shall be checked with the medical record and the original test report;
(5) Data that are significantly higher or beyond the acceptable range of clinical (laboratory examination items exceed 20% of the normal value) need to be verified, and the doctors participating in clinical trials shall make necessary explanations;
(6) After each subject has completed the observation course, the researcher shall submit the case report form and medical record to the main researchers of the unit for review and signature within 1 week.
3. the data verification inspector shall check whether the researcher follows the test plan during the test, and regularly go to the investigation site to check the informed consent and screening of the subjects;
(1) Confirm that all case report forms are filled in timely and correct, and are true and consistent with the original data; all errors or omissions shall be corrected or marked, signed by the researcher and dated;
(2) The withdrawal of the selected subjects shall be explained in the case report form; all adverse events shall be recorded and serious adverse events shall be reported and recorded within the specified time.
4. data entry and analysis
(1) Establish database: according to the items of case report form, the corresponding input program is established by computer software, and the logical review qualification conditions are set up during the entry, the database is put into trial operation and the database system dedicated to the test is established;
(2) Re check before entering: for further inspection of case report form, the case report form signed by the audit statement shall be submitted to the data administrator. The data administrator shall check the date, group entry standard, exclusion standard and missing value. If there is any doubt, the question form can be filled in and returned to the supervisor. The researcher shall answer and sign the questions in the question form in writing and return it to the data management The manager, the question form should be kept properly;
(3) Data entry: after training the data entry personnel, data entry is carried out. Each case report form adopts double entry method, which is completed by two persons independently;
(4) Data review: check the consistency between data entry and case report table results item by item, correct any inconsistency, and ensure that the data in the database are consistent with the results in the case report table;
(5) Data locking: in addition to the above data review, the main researchers, statisticians, data administrators and sponsors shall discuss and confirm the main contents and statistical analysis plan of the research plan. Confirm all data are entered into database, all questions have been solved, and data will be locked after analysis of the population has been defined and judgment is made.
(6) Data processing: statistical analysis shall be conducted by professional statistical analysts.
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