Correlates of Parental Participation During Informed Consent for Randomized Clinical Trials in the Treatment of Childhood Leukemia

This study described parent participation in the informed consent conference for randomized clinical trials (RCTs) in childhood leukemia and documented the relationship of physician communication to parent participation. Parents of 140 children with newly diagnosed leukemia who were eligible for RCTs were studied at six sites using comprehensive methods involving direct observation and transcripts of parent-physician communication based on audiotapes. Parent participation during the informed consent conference reflected a wide range of content categories. Consistent with hypotheses, Physician Rapport and Partnership Building related to parent participation in the informed consent conference but Information Giving did not. Higher parent socioeconomic status also was related to greater parent participation for two of the three measures of parent participation. Findings suggest that physician behaviors that provide support and facilitate communication may enhance parental participation in the informed consent conference for RCTs in childhood leukemia.

Searching for treatment outcome measures for use across trials

OBJECTIVE

Inconsistencies in outcome measures across studies of treatment efficacy have made comparisons among them difficult. As a result, there is interest in identifying one or more measures that might be recommended as universal indicators of outcome. The present article seeks to identify drinking, psychosocial and/or biological variables that could be candidates for use as universal indicators of change following alcoholism treatment.

METHOD

The primary data set included 128 alcohol-dependent men and women who were randomly assigned to cognitive-behavioral or interactional group treatment for 26 weekly sessions.

RESULTS

The greatest changes following treatment were seen in measures of drinking and drinking consequences. Correlational analyses indicated that changes from baseline in drinking consequences were significantly associated with changes in drinking. Psychosocial and biological indicators showed much smaller changes from baseline, and these were only weakly associated with changes in drinking, indicating that they are not sensitive measures of treatment-related change. The overall pattern of these findings was replicated in the Project MATCH data set.

CONCLUSIONS

It was concluded that drinking frequency and intensity measures, as well as a measure of drinking consequences, may be useful as universal indicators of alcohol treatment outcome, but that the other psychosocial and biological measures studied in these two data sets are not strong candidates for this purpose.

Perceptions of equipoise are crucial to trial participation: a qualitative study of men in the ProtecT study

Recruitment to trials is known to be difficult. Previous research suggests that a crucial factor may be participants' difficulty with the concept of randomization. This study explored patients' perceptions of randomization and reasons for consent or refusal to participate in the ProtecT study (a randomized trial of surgery, radiotherapy, and monitoring for localized prostate cancer). In-depth interviews were conducted with 21 men diagnosed with localized prostate cancer who were invited to participate in the ProtecT treatment trial. Interviewees were selected purposefully from three U.K. clinical centers to ensure the inclusion of similar proportions of those agreeing or refusing random treatment allocation in each of the treatment groups. Interviews explored men's recall and understanding of chance, comparison, and equipoise, and reasons for consent/refusal of randomization and acceptance/rejection of treatment allocation. Data were analyzed methodically using the techniques of constant comparison. Checking of coding and interpretation was assured by four experienced qualitative researchers. Recall and understanding of the major principles of the randomized design were good and were similar for "chance" and "comparison" between those who consented to and refused randomization. Clinical equipoise, however, caused difficulty. Almost all recalled and understood it, but those who found it acceptable tended to consent to randomization and those who could not accept it tended to refuse to participate. Belief in clinical equipoise was key to participants' consent to randomization. Ensuring patients understand and accept equipoise may thus increase their readiness to consent to participate in trials. A priority for future research is to focus on the provision and presentation of suitable and effective trial information, concentrating in particular on the neglected concept of clinical equipoise.

Longitudinal analysis of illness uncertainty, coping, hopefulness, and mood during participation in a clinical drug trial

The purpose of this longitudinal study was to examine the relationships among illness uncertainty, coping effectiveness, hopefulness, and mood in persons with chronic, progressive multiple sclerosis (MS) during participation in a double-blind clinical drug trial. The similarities and differences in the pattern of relationships among variables were investigated within each of four data collection time frames and across time. The convenience sample comprised 52 participants with clinically definite MS who participated in a 2-year trial using methotrexate to treat progressive MS. Participants with more severe disability were found to be less hopeful and more emotionally distressed. Participants with higher levels of hopefulness used more effective coping strategies and had more positive moods, and those with greater uncertainty about their MS were likely to experience less hopefulness and more negative moods. The pattern of relationships among uncertainty, coping, hopefulness, and mood did not change throughout participation in the drug trial. The findings may be used as a foundation for planning nursing interventions with patients involved in drug studies.

Are subjects satisfied with the informed consent process? A survey of research participants

OBJECTIVE

Letters of information (LOI) for clinical trials are becoming longer and more complicated. We investigated patients' perspectives of their ability to understand the information presented during a clinical trial. Satisfaction with and motivation for participation in clinical trials were also ascertained. Perceptions from various treatment disciplines were compared.

METHODS

Participants were chosen from 14 clinical trials (departments of rheumatology, ophthalmology, and cardiology) conducted at the same university. Subjects were asked to complete a written questionnaire that assessed demographic information, recall and understanding of information, subjects' decisions to participate, and perceptions/opinions of the study. The response rate was 75% (rheumatology, n = 74; ophthalmology, n = 32; cardiology, n = 84).

RESULTS

The majority of respondents (98%) indicated that they were satisfied with the informed consent process and with their involvement in a trial (97%). Subjects who reported having understood the LOI had better recall of placebo/active drug comparator (p < 0.03), and better understanding of why placebo was used (p < 0.04). No differences were found between those who reported understanding and those who did not on understanding the concept of concealed allocation (blinding). Subjects who felt they had received "the right amount of information" were more likely not to understand concealed allocation. The most frequent reason for trial participation was to help medical science (80%). Subjects with higher education were more likely to understand the reason for placebo use (p < 0.0003), but were not more likely to understand concealed allocation (p < 0.08).

CONCLUSION

Subjects reported that they were satisfied with the informed consent process and their experience in a clinical trial, and that they understood trial concepts. Subjects may be able to self-assess their own level of understanding for trial concepts that intrinsically make sense within the context of their beliefs about medical care, but other trial concepts may be misunderstood/misinterpreted regardless of self-assessment of understanding or education level (i.e., concealed allocation). Subjects may prefer to believe that investigators know which treatment they are receiving, and have made a good treatment decision specific to their case, despite having being told about concealed allocation and placebo use.

Outcomes from the Patient Perspective Workshop at OMERACT 6

The objective of the Patient Perspective Workshop at OMERACT 6 was to address the question of assessing the outcomes of intervention in rheumatoid arthritis (RA) from the perspective of those who experience the disease themselves. This was done by reviewing the current state of research in the area, identifying the requirements for the development of valid instruments, delineating a research agenda that can attain these requirements, and motivating participants to undertake the appropriate research. Through a series of meetings and discussion sessions a research agenda emerged that includes: exploring subjective experiences of RA identified by patients as important but not encompassed within the current "core set" of outcome measures (such as a sense of well being, fatigue, and disturbed sleep); clarifying terminology; and empowering patients to be more effective partners in outcomes research. These were supported by the OMERACT plenary session. Specific actions were required by both patient participants and organizers to ensure the nature of the conference, its focus and method of working were understood, and that the patient participants were sufficiently confident to make their contribution.

Rheumatology outcomes: the patient's perspective

Our aim was to explore the patient's perspective of outcomes in rheumatoid arthritis (RA) to identify which outcomes are important to patients and how patients calibrate what constitutes a meaningful change in those outcomes. A qualitative study was performed using focus groups in 5 clinical centers in different geographical locations in the UK. Each group contained 6 to 9 patients with RA who were purposefully sampled to include men and women with a range of age, disease duration, functional disability, work disability, and current disease activity. Each focus group lasted around 1 h and addressed 3 questions: What outcomes from treatment are important to RA patients? What makes patients satisfied or dissatisfied with a treatment? How do patients decide that a treatment is working? Patients identified as important not only physical outcomes such as pain and disability, but also fatigue and a general feeling of wellness. The relative importance of these outcomes depended on the stage of disease and on specific situations, such as a disease flare. Satisfaction was influenced by communication, access to treatment, and treatment efficacy. Treatment efficacy was related to symptom reduction, with the magnitude of reduction necessary for efficacy dependent on the stage of disease. For example, large changes were deemed necessary with disease of long duration, while in early disease, even small changes could be important. Our data support existing knowledge of the importance of pain and mobility as treatment outcomes, but raise new and important issues: Some outcomes of importance to patients are not currently measured and there are no measures available to capture them. Existing measures need to be calibrated to take account of the differing importance of outcomes at different stages of disease and variations in the magnitude of change within the same outcome that indicate treatment efficacy.

Should Providers of Treatment Be Regarded as a Random Factor? If It Ain't Broke, Don't "Fix" It: A Comment on Siemer and Joormann (2003)

In their criticism of B. E. Wampold and R. C. Serlin's analysis of treatment effects in nested designs, M. Siemer and J. Joormann argued that providers of services should be considered a fixed factor because typically providers are neither randomly selected from a population of providers nor randomly assigned to treatments, and statistical power to detect treatment effects is greater in the fixed than in the mixed model. The authors of the present article argue that if providers are considered fixed, conclusions about the treatment must be conditioned on the specific providers in the study, and they show that in this case generalizing beyond these providers incurs inflated Type I error rates.

Capturing users' experiences of participating in cancer trials

Randomized controlled trials are accepted to be the research design of choice to evaluate the effectiveness of health care interventions and are commonly used to evaluate cancer treatments. There are concerns, however, that levels of recruitment to trials are often much lower than anticipated, particularly in cancer trials. Several research methods have been used to collect aspects of users' experiences of participating in cancer trials. Perhaps the most common method has been through measures of outcome and the impact of treatments on quality of life (QoL), using standardized schedules to capture physical, social and psychological health. In some areas of cancer, individual patient testimonies illuminate particular issues or narratives. Another body of research has grown around issues of user involvement in trials, including surveys of recruitment and participation, as well as investigations of patient preferences and experiences of participation. We searched MEDLINE and the Cochrane Trials Library from 1995 to 2001 for relevant publications. In this article, we review the literature in these areas and examine whether users' experiences of participating in cancer trials can be used to assist in the design or conduct of trials.

Innovative designs in behavioural trials

Clinical trials that compare pharmacological and behavioural treatments require extra attention to design on the part of the investigators. Many of the standard control mechanisms for comparison of active drug to placebo and behavioural therapy to control therapy create problems when the two types of interventions are combined. The most important of these problems is the introduction of non-specific effects introduced by behavioural therapists and physicians that can bias the study. Solutions to these problems require procedures that are common to both types of studies and the introduction of more complex statistical designs to adequately control the proposed comparisons. It may also be necessary to have a robust statistical method to address informative censoring since patients assigned to behavioural therapy may drop out of the study for different reasons than patients who drop out of a pharmacological trial. In this paper we use the design of the Raynaud's Treatment Study to demonstrate methods that can be used to control for non-specific effects and differential drop-out from the study.

In randomized controlled trials, should subjects in both placebo and drug groups be expected to guess that they are taking drug 50% of the time?

Part of the design of some randomized controlled trials has included asking patients to guess whether they are taking placebo or active drug. Some authors have stated that in randomized, double-blind placebo-controlled clinical trials patients in each group should guess that they are taking placebo half the time. However, this pattern should occur only under a limited set of circumstances. This paper explores the factors that affect the guess and the role of the guess in understanding both the establishment and the maintenance of the blind. It suggests that more than half of those in the treatment group should guess they are taking active drug if treatment or side-effects are powerful. Though the randomized controlled trial has become the paradigmatic tool to assess treatment efficacy, studies are still needed to validate key assumptions make by investigators and the effect of violation of these assumptions on study outcomes.

Attitudes towards clinical research amongst participants and nonparticipants

OBJECTIVES

To investigate attitudes to clinical research amongst cancer trial participants and nonparticipants, and to compare results with those from previous studies amongst participants in noncancer trials.

DESIGN

Trial participating respondents were given three questionnaires during the clinical trials. Respondents amongst patients declining randomization answered a single questionnaire.

SETTING

Participants and nonparticipants in randomized clinical cancer trials.

SUBJECTS

Forty-one participants and 47 nonparticipants in cancer trials.

RESULTS

Altruistic motives of physicians to conduct medical research were highly rated. Attitudes towards clinical research were positive in all groups, with nonparticipant respondents being the least positive. Eight to nine tenths found scientific testing necessary before general health service implementation. Trial participants were, as compared with nonparticipating respondents, more positive towards both participation of self and others. Both personal and altruistic motives for participation were highly rated. Primary reasons for nonparticipation were fear of 'the unknown' and/or unease with randomization. Only a minority felt a moral problem created by declining trial participation. Respondents amongst noncancer participants were more satisfied with the information given than both cancer participants and cancer nonparticipants. Negative experiences in cancer participants generally dealt with frustration related to seeing too many physicians at check-up appointments.

CONCLUSION

Attitudes towards clinical research are generally positive even in cancer nonparticipants. Both personal and altruistic motives for participation were highly rated. A fear of 'the unknown' and resentments towards randomization were primary reasons to renounce participation. Seeing too many physicians at check-up appointments seems to be an important factor for negative experiences in cancer trial participants.

Timing of quality of life (QoL) assessments as a source of error in oncological trials

AIM OF THE STUDY

To produce an empirical estimate of the nature and magnitude of the error produced by incorrect timing quality of life (QoL) measurements in patients receiving chemotherapy.

DESIGN

In a multicentre trial, 283 patients were randomized to receive either docetaxel (T) or sequential methotrexate and 5-fluorouracil (MF). The QoL was assessed at baseline and before each treatment using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). The study design was retrospective. Data were analysed using t-tests.

RESULTS

Erroneous timing affected the QoL findings in both treatment arms. At baseline, there were statistically significant differences in the MF group on the nausea/vomiting scale, with ill-timed assessment showing more symptoms, and in the T group on the physical functioning scale with ill-timed assessments indicating better QoL. The mean scores of correct vs. incorrect timings over the first 14 cycles showed statistically significant differences on several scales. In the MF group, ill-timed assessments indicated significantly worse physical functioning and global QoL, and significantly more of the following symptoms: fatigue, nausea/vomiting, insomnia, appetite loss, and constipation. In the T group, ill-timed assessment showed better physical functioning, less dyspnoea and more insomnia than correctly timed assessments. The reasons for erroneous timing were not always detectable retrospectively. However, in some cases the MF group, being in standard treatment, seemed to have followed a clinical routine not involving the active participation of the study nurse responsible, whereas patients in the experimental T group were more consistently taken care of by the study nurses.

CONCLUSIONS

Incorrect timing of QoL assessments in oncological trials jeopardises both the reliability of the QoL findings within treatment and the validity of QoL outcome comparisons between treatments. This issue should be emphasized in the planning of both the study design and clinical routines.

Randomized clinical trials in oncology: understanding and attitudes predict willingness to participate

PURPOSE

To explore the association at different time points in the trajectory of breast cancer care, between anxiety, knowledge, and attitudes, on women's willingness to participate in randomized clinical trials.

MATERIALS AND METHODS

A cross-sectional survey was undertaken among women attending a breast clinic for screening mammography or diagnostic assessment plus women with newly diagnosed breast cancer to assess attitudes toward and willingness to participate in randomized clinical trials of breast cancer treatment.

RESULTS

Five hundred forty-five women completed questionnaires assessing knowledge of and attitudes toward randomized clinical trials. The mean age of respondents was 48.9 years (SD, 11.3 years). Thirty-three percent of women would consider participating in a clinical trial if they had breast cancer. Women with breast cancer (31%) were significantly more likely to decline to participate than women attending for screening mammography (15%) or diagnostic assessment (15%, P =.0002). Women who might consider participating in a randomized clinical trial were more knowledgeable about randomized trials (mean difference, 0.7; 95% confidence interval [CI], 0.2 to 1.2; P =.003). In a multivariate analysis, women who would consider participating in a randomized trial were younger (odds ratio [OR], 0.96; 95% CI, 0.93 to 0.99), more likely to want an active role in decision-making (OR, 3.2; 95% CI, 1.3 to 7.6), and reported a greater impact from the positive aspects of clinical trials (OR, 2.2; 95% CI, 1.3 to 3.8) and less impact from the negative aspects of clinical trials (OR, 2.2; 95% CI, 1.3 to 3.2).

CONCLUSION

These findings suggest that women who have a better understanding of issues about clinical trials have more favorable attitudes toward randomized trials and are more willing to consider participation in a clinical trial.

Psychiatric outpatients report their experiences as participants in a randomized clinical trial

We conducted exit interviews with 45 outpatients with severe and persistent mental illness (SPMI) who had participated in a randomized clinical trial. The interviews followed a semistructured format and were audiotaped for later transcription and rating by two independent raters. Content analyses of the interviews revealed that most participants evaluated their experiences quite favorably. For example, most noted that the assessment process was thought-provoking and motivational and that the intervention groups led to increased self-confidence and new friendships. Although a few participants noted that the assessment contained sensitive material, all appreciated the frequent reminders that information disclosed was strictly confidential. These results indicate that persons living with a SPMI often enjoy participating in behavioral research, which can yield immediate benefits to patient-participants. Exit interview research such as this can help investigators to understand reasons for consent and participation, to identify needs for protocol modifications, and to facilitate the integration of evidence-based interventions into the mental health care systems.

United Kingdom Alcohol Treatment Trial (UKATT): hypotheses, design and methods

The United Kingdom Alcohol Treatment Trial (UKATT) is intended to be the largest trial of treatment for alcohol problems ever conducted in the UK. UKATT is a multicentre, randomized, controlled trial with blind assessment, representing a collaboration between psychiatry, clinical psychology, biostatistics, and health economics. This article sets out, in advance of data analysis, the theoretical background of the trial and its hypotheses, design, and methods. A projected total of 720 clients attending specialist services for treatment of alcohol problems will be randomized to Motivational Enhancement Therapy (MET) or to Social Behaviour and Network Therapy (SBNT), a novel treatment developed for the trial with strong support from theory and research. The trial will test two main hypotheses, expressed in null form as: (1) less intensive, motivationally based treatment (MET) is as effective as more intensive, socially based treatment (SBNT); (2) more intensive, socially based treatment (SBNT) is as cost-effective as less intensive, motivationally based treatment (MET). A number of subsidiary hypotheses regarding client-treatment interactions and therapist effects will also be tested. The article describes general features of the trial that investigators considered desirable, namely that it should: (1) be a pragmatic, rather than an explanatory, trial; (2) be an effectiveness trial based on "real-world" conditions of treatment delivery; (3) incorporate high standards of training, supervision and quality control of treatment delivery; (4) pay close attention to treatment process as well as treatment outcome; (5) build economic evaluation into the design at the outset. First results from UKATT are expected in 2002 and the main results in 2003.

Who's afraid of the randomised controlled trial? Parents' views of an SLT research study

Evidence-based health care is now a reality within the national health service (NHS) and the randomised controlled trial (RCT) is the linchpin of this movement. In modern health care, there has also been a shift towards understanding client perspectives. With regard to clients' participation in research, much consideration has been given to ethical issues and barriers to participation. However, less attention has been paid to the participants' views of clinical trials and understanding how they construe the research. This paper reports a study of the attitudes of parents whose children took part in an RCT. Data were collected from the parents of 20 children, using qualitative in-depth interviews. Parents talked about the meaning of their participation, their motivation for taking part and their understanding of the nature of the trial. The implications of the findings for future research will be considered.

Inclusion of older women in randomized clinical trials: factors associated with taking study medication in the fracture intervention trial

OBJECTIVES

The purpose of this study is to describe the early study medication discontinuation (SMD) experience during the first year of follow-up in a randomized clinical trial in older women and to determine the associations between various baseline characteristics and risk of SMD. DESIGH, SETTING, AND PARTICIPANTS: The authors studied 6,459 postmenopausal women aged 55 to 80 from 11 clinical settings during their first year of participation in the Fracture Intervention Trial (FIT). This trial was designed to test the efficacy of alendronate (Fosamax) on fracture prevention among women with low bone mass.

RESULTS

Study medication discontinuation was greatest in the first month post-randomization (2.2%) and declined thereafter. Cumulative rates of study medication discontinuation were 4.8% (n = 311) at 3 months and 11.1% (n = 717) at 12 months. SMD was not associated with age, marital status, alcohol consumption, regular exercise, past estrogen replacement therapy use, bone mineral density, or personal or maternal fracture history. After adjusting for covariates and markers of comorbidity, the strongest predictor of SMD was fair-to-poor self-rated health (relative risk (RR) 2.10; 95% confidence interval (CI) 1.47, 2.99). Having four or more depressive symptoms was also a significant predictor and had a risk associated with SMD (RR vs none 1.34; 95% CI 1.05, 1.71) similar to that seen for individuals with good self-rated health (RR 1.49; 95% CI 1.16, 1.91).

CONCLUSIONS

Results from this cohort emphasize that clinical trials in older women with multiple concomitant conditions can achieve high levels of adherence. Thought should be given to measuring self-rated health and depressive symptoms before randomization to help identify individuals to be targeted for special assistance programs that focus on encouraging adherence.

Challenges posed by non-random missing quality of life data in an advanced-stage colorectal cancer clinical trial

Effects of variations in agent, dose, and route of treatment administration on patient reported quality of life (QOL) were examined for 279 patients enrolled on a seven-arm randomized clinical trial (S8905) of 5-FU and its modulation for advanced colorectal cancer. Patients completed QOL questionnaires at randomization and weeks 6, 11, and 21 post-randomization with five QOL endpoints considered primary: three treatment-specific symptoms (stomatitis, diarrhea, and hand/foot sensitivity); physical functioning; and emotional functioning. Patient compliance with the QOL assessment schedule was good, supporting the feasibility of including QOL measures in cooperative group trials. However, death and deteriorating health produced substantial missing data. Cross-sectional analyses indicated that the seven therapeutic arms did not differ in their impact on QOL. Unfortunately, longitudinal analyses of the QOL data were inappropriate given non-random missing data. Graphical presentation of non-random missing data identified the seriousness of this problem and its effect on potential conclusions about QOL during treatment. This problem appears to be particularly challenging in the context of advanced-stage disease. Failure to recognize the presence of non-random missing data can lead to serious overestimates of patient QOL over time.

Patient comprehension and reaction to participating in a double-blind randomized clinical trial (ISIS-4) in acute myocardial infarction

BACKGROUND

Although randomized clinical trials are currently the standard for the evaluation of new therapeutic strategies, little attention has been paid to the viewpoint of the patients recruited to these trials.

OBJECTIVES

To examine the perspective of the Israeli patient cohort who participated in the Fourth International Study of Infarct Survival, a randomized trial in acute myocardial infarction.

METHODS

A patient questionnaire was mailed to 360 Israeli patients who participated in the Fourth International Study of Infarct Survival and was returned by 150 of them. Main outcome measures included patient perception of consent procedures, comprehension of the study, subjective reaction to participating in the trial, and interest in present and future trials.

RESULTS

Forty (31%) of 129 patients perceived that they had full comprehension of the trial, while 64 (50%) claimed partial understanding and 25 (19%), no understanding at all. Comprehension was related to a recollected explanation of 5 minutes or more (P<.001) and to an opportunity for discussion at the time of consent (P<.001). Most patients recollected the oral explanation; fewer, the written material. Patient consent was given by 64 (43%) of 150 patients in the hope of better treatment. In 36 cases (25%), the patients felt they received better treatment because of participation in the trial.

CONCLUSIONS

Despite proper attention to accepted ethical and legal standards, perceived patient comprehension in this trial in acute myocardial infarction was incomplete or lacking in a considerable number of subjects. Much progress must be made toward the goal of true informed consent in clinical trials.

Determinants of patients' treatment preferences in a clinical trial

Several researchers have suggested that patients' preferences for a particular form of treatment should be taken into account in clinical trials. Preferences may influence the outcome of treatment, especially in trials when patients cannot be blinded to the type of treatment received and the outcome is based on patients' evaluations of therapy. Participants in this study were 136 edentulous patients who took part in a randomised controlled clinical trial comparing two types of treatments for edentulism: conventional dentures and implant-supported prostheses. Prior to receiving treatment, subjects were required to complete a questionnaire regarding their satisfaction with their present prostheses. In addition, they were asked to indicate which treatment they would prefer if given a choice. The objective of this study was to determine whether there are important differences among study participants between patients who have a treatment preference and those who do not. The effects of satisfaction with pre-treatment prostheses, age, gender and level of education on preferences were examined. Level of satisfaction with the original dentures and level of education were significant predictors of preference. Compared to subjects who rated their satisfaction with their current condition as 'low', the odds ratios associated with having a preference for implant treatment were 0.31 (95% CI: 0.09 to 0.96) for subjects who rated their prostheses in the 'medium' range and 0.11 (95% CI: 0.03 to 0.41) for those who rated in the 'high' range. In addition, subjects with high levels of education were significantly less likely to have a preference for either conventional or implant treatments (OR = 0.18, 95% CI: 0.02 to 0.77 and OR = 0.20, 95% CI: 0.05 to 0.76, respectively) compared to those with low education. Neither age nor gender was a significant predictor of preference. We suggest that study designs which incorporate patients' preferences must take into account possible differences between preference groups that might confound the relationship between preference and the outcome of interest.

Paying research subjects: participants' perspectives

OBJECTIVE

To explore the opinions of unpaid healthy volunteers on the payment of research subjects.

DESIGN

Prospective cohort.

SETTING

Southern Alberta, Canada.

PARTICIPANTS

Medically eligible persons responding to recruiting advertisements for a randomised vaccine trial were invited to take part in a study of informed consent at the point at which they formally consented or refused trial participation. Of 72 invited, 67 (62 trial consenters, 5 trial refusers) returned questionnaires at baseline and 54 at follow-up.

OUTCOME MEASURES

Proportions of persons who agreed or disagreed with three close-ended statements on the payment of research subjects; themes and categories identified by content analysis of responses to an open-ended question.

RESULTS

A minority (43.3%) agreed with paying either patient or healthy volunteer participants. Opinions did not change over time. Participants' comments addressed: benefits and drawbacks to research participation; benefits and drawbacks to paying research participants; conditions under which payment of research subjects would be acceptable, and the nature of acceptable recognition. Acceptable conditions were to improve problematic recruitment, to reimburse costs, and to recognise participants, particularly for their time investment. Both non-monetary and monetary recognition of volunteers were thought to be appropriate.

CONCLUSIONS

Most unpaid volunteers disagreed with paying research participants. The themes arising from their comments are similar to those that have been raised by ethicists and suggest that recognising the time and effort of participants should receive greater emphasis than presently occurs.

Self-reported diagnostic and management strategies in childhood idiopathic thrombocytopenic purpura: results of a survey of practicing pediatric hematology/oncology specialists

PURPOSE

To assess current physician self-reported practices regarding initial management of childhood idiopathic thrombocytopenic purpura (ITP) and to determine physician self-reported willingness to participate in randomized clinical trials comparing different initial management strategies.

PATIENTS AND METHODS

A questionnaire was mailed in November 1997 to all 720 members of the American Society of Pediatric Hematology/Oncology asking how they would diagnose and manage ITP in children 18 months, 5 years, and 15 years of age who were experiencing either dry purpura (cutaneous hemorrhage only) or wet purpura (active mucous membrane hemorrhage). Specific questions dealt with bone marrow aspiration, hospital admittance, treatment strategy, and specific doses of corticosteroids and intravenous immunoglobulin.

RESULTS

The response rate to the questionnaire was 57%. Most respondents indicated they usually perform a bone marrow aspirate when corticosteroids are to be prescribed and administer drug therapy to patients with newly diagnosed ITP with wet or dry purpura. Only 16% of respondents would administer no drug therapy to a child with dry purpura. Intravenous immunoglobulin (IVIG) was preferred to steroids, with anti-D immunoglobulin prescribed less frequently. Hospital admittance often was used for patients with dry purpura and usually recommended for patients with wet purpura. Most respondents expressed willingness to randomize patients with dry purpura to IVIG versus no therapy and those with wet purpura to IVIG versus prednisone as part of a randomized controlled clinical trial.

CONCLUSIONS

The self-reported care of the patient with ITP was influenced by the severity of presentation (dry versus wet purpura). Most physicians reported they would administer specific drug treatment in both scenarios. This survey illustrates the diverse diagnostic and management strategies currently used in childhood ITP. Because no one therapeutic approach is predominant and a scientific basis for decision making in childhood ITP has not been developed, future randomized trials are warranted. On the basis of these survey results, such trials are desired by most pediatric hematology/oncology specialists.

General practitioners' attitudes to randomised clinical trials for women with breast cancer

OBJECTIVE

To determine general practitioners' attitudes to randomised clinical trials for women with breast cancer.

DESIGN

Cross-sectional survey with structured face-to-face interviews conducted between December 1997 and May 1998.

PARTICIPANTS

A random sample of GPs in central Sydney.

MAIN OUTCOME MEASURES

GPs' attitudes to referring women with breast cancer to specialists who enrol patients in randomised clinical trials, and to randomised clinical trials in general.

RESULTS

85 of 158 GPs (54%) consented to be interviewed. Of these 85 GPs, 47% stated that they would refer a woman with breast cancer to a specialist who was likely to enrol the woman in a clinical trial; 50% believed that clinical trials increase knowledge about treatment options; and 15% thought that randomised trials may make a valuable scientific contribution. However, 43% of GPs expressed concerns that their patients may be disadvantaged, 39% said that they wanted optimum treatment for their patients, 18% that they would want to know what the trial was about, and 12% were worried about ethical considerations.

CONCLUSIONS

Many of the GPs in this survey have concerns about randomised clinical trials for women with breast cancer. Improved communication between specialists and GPs about the conduct of and treatments offered in clinical trials for breast cancer may change this attitude.

Parents' perceptions of randomization in pediatric clinical trials. Children Cancer Group

OBJECTIVES

The purpose of this study was to investigate parents' knowledge and perceptions about randomization in clinical trials for children with cancer, and to determine whether parents' decisions were influenced by demographic factors, randomization circumstances, the clinical characteristics of the child with cancer, or a combination.

MATERIALS AND METHODS

This study collected information from 192 parents of patients with various forms of childhood cancer who either accepted or refused randomization. A comparative case-control design was used. The Clinical Investigation Randomization Scale was administered to all participants. This scale included 32 questionnaire items (QIs) pertaining to randomization as well as a mixture of open-ended questions to obtain information about demographic and other factors.

RESULTS

A predictor model was developed that accurately predicted acceptance or refusal of randomization 87% of the time. Demographic information was found to have less influence than expected on parents' decisions regarding randomization. Knowledge deficits were found among both groups of parents, those who accepted and those who refused randomization.

CONCLUSIONS

What most distinguished parents who refused from those who accepted randomization was not their knowledge and information about randomized clinical trials. By far, the majority of QIs that accurately predicted acceptors and refusers involved parents' beliefs, values, and perceptions. Further research is needed to determine interventions that may enable the healthcare team to provide information and decisional support most effectively to improve the informed consent process.

[Consent to enrollment in randomized clinical trials]

Multi-facility joint randomized clinical trials for cancer treatment are the most common method of current clinical study. However, the difference in the rate of participation in multi-facility randomized clinical trials may damage the resulting general validity. Therefore, we studied whether the rate of participation in randomized clinical trials is different between university hospitals and other general hospitals using a questionnaire (with anonymity preserved). There were 744 subjects from university hospitals and 339 from general hospitals participating in the study. The results showed that 10.9 percent of those from university hospitals were willing to participate, against 28.1 percent who were not. Of those from general hospitals (public hospitals in this study) 10.6 percent answered that they would participate and 27.4 percent that they would not. Little difference was found in the rate of participation in randomized clinical trials between university hospitals and other general hospitals. The focus is thus on doctors to solve the possible differences between the facilities in further multi-facility joint studies.

Zelen randomization: attitudes of parents participating in a neonatal clinical trial

Recruitment to randomized controlled trials can be difficult for all parties involved. An alternative to the standard process has been suggested for trials in which the control group receives standard treatment or nontreatment. In this approach (the Zelen design), randomization precedes consent, which is only sought from those allocated to the experimental arm of a trial. The control group is thus unaware that randomization has taken place. As a controversial method, this approach has been often suggested but rarely used. Here we describe how 44 parents recruited to a difficult neonatal trial that used conventional randomization reacted to the idea of Zelen randomization. The arguments they gave for and against the method pertain to four areas: the giving or withholding of information, the effect on decision making, the use of data without parental knowledge, and the long-term impact for parents. The parents were evenly divided in accepting or rejecting the method. Further analysis showed that those rejecting Zelen randomization were more likely to be parents of infants allocated to the control group. This suggests that those from whom consent would not be sought, the group that this approach is primarily meant to protect, are most likely to find it unacceptable.

The views of nurses to the conduct of a randomised controlled trial of problem drinkers in an accident and emergency department

The Trent Regional Health Authority funded a study in 1995 to train nurses in an accident and emergency (A&E) department to screen all adult attendees for alcohol problems with a view to identifying a sample of problem drinkers to participate in a randomised controlled trial (RCT). In the RCT identified drinkers were to be assigned either to health education plus brief counselling intervention or, as controls, to health education alone. Despite 16654 attendance's at A&E during the recruitment phase of the study only 20% of attendees were screened of whom a further 19% were identified as problem drinkers by the CAGE screening questionnaire. Less than half of the problem drinkers were, however, provided with feedback by the nurses, leaving a small group of 264 eligible for entry to the RCT. The great majority of this subgroup refused an initial appointment at the specialist clinic and so the trial was abandoned. A number of in-depth interviews were undertaken with the nurses in an attempt to understand ways in which the overall conduct of the study might have been improved. This paper outlines in some detail some of the reasons for the lack of success with the study which include; general environmental factors that undoubtedly led to stress and poor morale amongst the nursing team, the differences in perception between managers and clinical nurses concerning the value of research and the inadequacy of the initial training programme. The paper concludes that there are problems in the NHS which do not provide a helpful backcloth to the successful conduct of health services research.

Quantitative assessment of recruitment efforts for prevention trials in two diverse black populations

BACKGROUND

Prevention efforts to reduce the morbidity and mortality disparity between blacks and whites in the United States present a national health priority. However, participation of blacks in prevention trials has been low. The present study reports successful recruitment processes from two economically diverse black populations.

METHODS

The two studies were independent projects, but both were part of a nationally funded collaboration on cardiovascular health. "Hip Hop to Health" is a 4-year randomized controlled trial aimed at dietary fat reduction and increased exercise among inner-city black families. The Fat Reduction Intervention Trial in African-Americans project is a 5-year trial to reduce total fat, saturated fat, and cholesterol intake among black families from a working class community.

RESULTS

The two populations differed on demographic characteristics. Direct presentation was the most effective recruitment strategy in the "Hip Hop to Health" program. In contrast, telephone recruitment and neighborhood canvassing were the more successful strategies for FRITAA.

CONCLUSIONS

Although both populations were black and at comparable cardiovascular disease risk, the differing demographics between the groups made different recruitment strategies necessary. This study documented the labor-intensive quality of successful recruitment, and results suggest that successful recruitment requires strategies tailored to the needs, experiences, and environment of the target group.

Random allocation or allocation at random? Patients' perspectives of participation in a randomised controlled trial

OBJECTIVES

To explore trial participants' understandings of randomisation.

DESIGN

In this exploratory study, which used qualitative research methods, in-depth, semistructured interviews were carried out with 20 participants from the CLasP randomised controlled trial. Interviews were recorded on audio tape and fully transcribed. Data were analysed by comparing transcripts and describing emergent themes, using a grounded theory approach.

SETTING

The CLasP study comprises three linked multicentre, pragmatic randomised controlled trials evaluating the effectiveness and cost effectiveness of laser therapy, standard surgery, and conservative management for men with lower urinary tract symptoms or urinary retention, or both, related to benign prostatic disease.

SUBJECTS

20 participants in the CLasP study were interviewed. Sampling was purposeful: men were included from each of the treatment arms, the two major centres, and at different points in the trial.

INTERVENTIONS AND OUTCOME MEASURES

Interviews used a checklist of topics to encourage participants to describe their experiences. Narratives concerning randomisation were compared to identify common themes, retaining the context of the discussion to allow detailed interpretation.

RESULTS

Most participants recalled and described aspects of randomisation, such as the involvement of chance, comparison, and concealed allocation. Many found the concept of randomisation difficult, however, and developed alternative lay explanations to make sense of their experiences. Inaccurate patient information and lay interpretations of common trial terms caused confusion.

CONCLUSIONS

The provision of clear and accurate patient information is important, but this alone will not ensure consistent interpretation of concepts such as randomisation. Patients may need to discuss the purposes of randomisation in order to understand them fully enough to give truly informed consent.

The use of equipoise in clinical trials

Randomised control trials (RCTs) are the standard method for treatment evaluation. Unfortunately RCTs are inherently difficult to recruit for, precisely because of the randomisation element that makes them so statistically attractive. Problems of low recruitment are now beginning to impact on trials, with many either not being started or being forced to stop, due to lack of participation. This paper examines one issue that bears on the recruitment problem: equipoise. Equipoise is defined as the point where a rational, informed person has no preference between two (or more) available treatments (Lilford and Jackson, 1995). The use of equipoise as the fundamental criterion for eligibility for a trial seems to impose a hurdle to recruitment. Here we examine the various arguments surrounding its use and measurement. We conclude that effective equipoise based upon constructed "zones of indifference" offers the best chance for bridging the gap between the individual's right to decide and the need for clinical trials to benefit society.

Attitudes of patients to randomised clinical trials of cancer therapy

The aim of this study was to test an instrument which might be useful for doctors in explaining the randomisation procedure to an individual patient. The sample comprised 323 patients with cancer attending for out-patient appointments and/or chemotherapy treatment in two major cancer centres in the U.K. 315 patients completed a self-report questionnaire--The Attitudes to Randomised Trials Questionnaire (ARTQ). The results show that the majority of subjects 287 (91.1%) believe that patients should be asked to take part in medical research, but only 242 (76.8%) would be prepared to take part in a study comparing two treatments. If treatment was randomised, only 141 (44.8%) would agree to participate. When given further information about the randomisation procedure, 119 (68.4%) of the 174 (55.2%) who initially said 'no' to randomisation or who were unsure, would change their minds and take part in a trial. The ARTQ discriminated between three categories of patient with the following prevailing attitudes: (a) those who seem comfortable with the concept of randomisation; (b) those with some concerns, who with fuller explanation are prepared to consider randomisation; and (c) those firmly against randomisation and participation in trials whatever information is provided. Prior knowledge of patients' attitudes might assist communication about trials and encourage more doctors to approach eligible patients.

Reactions of participants to the results of a randomised controlled trial: exploratory study

OBJECTIVES

To assess views of parents of babies who participated in a neonatal trial, about feedback of trial results.

DESIGN

Qualitative analysis of interviews.

SETTING

Parents' homes.

SUBJECTS

Parents of 24 surviving babies enrolled in a UK randomised controlled trial comparing ventilatory support by extracorporeal membrane oxygenation with conventional management.

MAIN OUTCOME MEASURES

Views about contents of results, reactions to results, effect of hindsight, and importance of feedback.

RESULTS

Information about mortality was well understood by the parents but morbidity was less clearly reported. Even when the content was emotionally exacting, the information was still wanted as it removed uncertainty; provided an endpoint to difficult events; promoted further discussion within couples; and acknowledged their contribution to answering an important clinical question.

CONCLUSIONS

Feedback of trial results to participants should be a consideration of researchers, but a careful approach is required. This study was based on a highly selective group of parents within a particularly sensitive trial. More research is needed to assess the extent to which these results can be generalised to other trials or to groups such as bereaved parents.

Patients' perceptions of their participation in a clinical trial for postoperative Crohn's disease

OBJECTIVE

To explore patients' perceptions of their participation in a randomized controlled trial.

PATIENTS AND METHODS

A 27-item questionnaire was mailed to all patients who participated in a randomized controlled trial that determined the effectiveness of mesalamine in preventing the recurrence of Crohn's disease postoperatively.

RESULTS

The response rate was 66% (99 of 149). Fifty-five per cent of the patients felt that they received better medical care than they otherwise would have and 53% liked taking the medication. Sixty-eight per cent of the patients did not feel that annual colonoscopy was too frequent and 81% felt that the time commitment did not significantly interfere with their job or other activities. Seventy-five per cent and 62% of the patients would have liked more information and education, respectively, about Crohn's disease incorporated into the trial. Although 91% of the patients would agree to participate in a future randomized controlled trial comparing medical therapies, only 44% would agree to participate in a future randomized controlled trial comparing medical with surgical therapies.

CONCLUSIONS

The majority of patients were satisfied with their participation in the trial. A large proportion of the patients would participate again but would like more information and education incorporated into the trial. Furthermore, post-trial questionnaires may be helpful in the design of future trials.

Offering a randomized trial of intensive therapy for IDDM to adolescents. Reasons for refusal, patient characteristics, and recruiter effects

OBJECTIVE

To identify reasons adolescents refuse to participate in a randomized trial of intensive therapy (IT) for IDDM, to describe the patient characteristics of those who consent and those who refuse to participate, and to examine recruiter effects on trial participation rates.

RESEARCH DESIGN AND METHODS

A total of 99 adolescents, age 11-18 years, were provided with the results of the Diabetes Control and Complications Trial and approached for possible study participation by two nurse recruiters. Adolescents refusing the trial were administered a semi-structured interview to describe reasons for study refusal; responses were recorded and later coded into categories. Patient characteristics of consenters and refusers were collected and compared. The differential enrollment rates of the two nurse recruiters were also compared.

RESULTS

A total of 56 patients (approximately 57%) agreed to participate; 43 refused. The four most common reasons for study refusal were 1) increased clinic visits (42%), 2) increased insulin injections (30%), 3) increased frequency of self-monitoring of blood glucose (SMBG) (28%), and 4) transportation difficulties (19%). Concerns about randomization to an unwanted treatment condition and fears of hypoglycemia or weight gain were rarely cited. Consenters and refusers did not differ in demographic characteristics, disease status, or family composition. Large differences were found between the two nurse recruiters: one experienced a 60% refusal rate, while the other experienced a 27% refusal rate.

CONCLUSIONS

Issues of convenience (increased clinic visits, transportation difficulties) and concerns about the demands of IT (increased injections and SMBG) were the predominant reasons for trial refusal. Patient characteristics did not differentiate consenters from refusers. However, recruiters differed greatly in study refusal rates, suggesting that provider behavior may be an important but understudied aspect of adolescent acceptance of randomized trials in general and IT in particular.

How preliminary data affect people's stated willingness to enter a hypothetical randomized controlled trial

PURPOSE

To explore how preliminary trial data affect the general public's stated willingness to enter a randomized clinical trial.

METHODS

We asked 165 prospective jurors to imagine that their physicians wanted them to enroll in a clinical trial. We then presented them with scenarios portraying preliminary trial results--for example, 9 out of 10 patients get better with drug A and 5 out of 10 get better with drug B--and asked after each scenario, whether they would choose to be part of the trial. We designed the scenarios to test how stated willingness to enter the trial would be influenced by: 1) the difference in effectiveness of the 2 treatments based on the patients enrolled thus far; and 2) by the chance that the difference in effectiveness was random (i.e., the P value). The subjects' willingness to enter the trial at various decision points was analyzed using logistic regression.

RESULTS

Fewer subjects were willing to enter the trial as preliminary data indicated either an increasing difference in the effectiveness of the two treatments or an increasing statistical significance of that difference. For example 75% of subjects were willing to enter the research trial before any preliminary data were presented, but this number fell to 49% when subjects were presented with preliminary data showing that 9 out of 10 patients improved with one treatment and 5 out of 10 with the other. Multivariable logistic regression revealed that higher P values (odds ratio = 4.29; P < 0.001; 95% CI: 2.22-8.28) and smaller differences in effectiveness (odds ratio = 0.02; P < 0.001; 95% CI: 0.00-0.07) implicit in preliminary data presented to subjects made subjects less likely to agree to enter clinical trials. After adjustment for other relevant variables, male gender was associated with increased willingness to enter the trial.

CONCLUSION

A subjects' willingness to enter the hypothetical trial was influenced by preliminary data. Fewer subjects were willing to enter the trial as the differences in benefit between 2 treatment groups increased. However, the majority of subjects were willing to enter the hypothetical trial even when preliminary evidence strongly favored one treatment over another. Given the importance of informed consent in entering patients in clinical trials, these results should be confirmed in actual trial settings.

Recruitment and retention of homeless mentally ill participants in research

Are the unstable residential and personal lives of homeless mentally ill (HMI) individuals so difficult as to preclude their inclusion in rigorous, longitudinal research protocols? The continued presence of HMI individuals in U.S. society has prompted the mental health research community to reconsider the question of whether clinical trial and demonstration research protocols are feasible with this population. This article briefly examines the existing research literature on recruitment and retention rates in recent studies of this population and, in more detail, the specific strategies used by researchers to recruit and retain HMI individuals as research participants. In general, with sufficient resources and the persistent use of existing strategies for recruitment and retention, HMI individuals can be successfully studied over time. Finally, to demonstrate this potential, the recruitment and retention strategies of the San Diego McKinney Homeless Mentally Ill Demonstration Research Program are described.

Factors related to enrollment in the breast cancer prevention trial at a comprehensive cancer center during the first year of recruitment

BACKGROUND

Using an a priori theoretic model of behavior change, factors predicting enrollment in a randomized chemoprevention trial during the first year of recruitment were assessed prospectively.

METHODS

Eligible participants were asked to complete a 90-item semistructured questionnaire after attendance at an informational meeting. Components of the Health Belief Model (including perceived susceptibility, perceived severity, perceived benefits and barriers, cues to action, and health motivation), health status, preventive health behaviors, and social influence were assessed in relation to enrollment.

RESULTS

Overall, 331 women attended one of the meetings, and 73% completed a questionnaire; 45% enrolled on the trial and 55% did not. In bivariate analyses, all but one of the perceived barriers were associated negatively with enrollment; however, items assessing perceived susceptibility, perceived severity, and perceived benefits were not. Nonparticipants also were more likely to be over 49 years of age, to be currently or to have been on estrogen replacement therapy, and to have had hot flashes. In logistic regression analysis, not being able to take estrogen replacement therapy was the strongest predictor of nonparticipation (odds ratio [OR], 12.13, 95% confidence interval [CI], 3.63, 40.60). Other factors associated with nonparticipation were concern about side effects of tamoxifen (OR, 5.06; CI, 2.37, 10.80); the possibility of getting a placebo (OR, 7.75; CI, 1.51, 39.67); the costs associated with the trial (OR, 3.21; CI, 1.12, 9.24); and absence of concern that significant others would be reassured if the respondent was taking tamoxifen (OR, 2.58; CI, 1.04, 6.41).

CONCLUSIONS

These findings support the view that recruitment efforts for chemoprevention trials should address barriers specific to their circumstances. In addition, increasing the support available from personal social networks may enhance recruitment to chemoprevention trials for breast cancer.

Who says yes? Identifying selection biases in a psychosocial intervention study of multiple sclerosis

The purpose of this work is to examine whether patients' sociodemographic and medical characteristics are associated with participation in a randomized controlled trial of two psychosocial interventions. After elimination of basic ineligibles from a registry of multiple sclerosis patients, 325 patients were sent a letter inviting participation in the randomized trial. Among those invited, 29% expressed an interest in participating, 19% scheduled an intake interview and 13% were actually randomized. chi 2 and logistic regression analyses were used to determine what factors were associated with successive stages of participation or non-participation in the study. Differential referral and participation rates could be traced in part to physician factors. With respect to patient factors, people were more likely to participate in the successive stages of recruitment if they had a higher median family income, lived a moderate distance from the hospital, and were disabled from working. Multivariate analyses of patient factors revealed that having a higher income and being disabled from work were the strongest predictors of participation, after adjusting for the effects of course of disease, disability status, and other sociodemographic predictors. Implications of these findings are discussed in terms of potential sources of bias in the selection of eligible patients, as well as the role the investigator may play in highlighting or underplaying this selection bias. Suggestions are made to minimize the bias-generating barriers.