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Tzeng DS, Wu YC, Hsu JY. Latent variable modeling and its implications for institutional review board review: variables that delay the reviewing process. BMC Med Ethics 2015; 16:57. [PMID: 26311634 PMCID: PMC4551705 DOI: 10.1186/s12910-015-0050-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 08/18/2015] [Indexed: 11/10/2022] Open
Abstract
Background To investigate the factors related to approval after review by an Institutional Review Board (IRB), the structure equation model was used to analyze the latent variables ‘investigators’, ‘vulnerability’ and ‘review process’ for 221 proposals submitted to our IRB. Methods The vulnerability factor included vulnerable cases, and studies that involved drug tests and genetic analyses. The principal investigator (PI) factor included the license level of the PI and whether they belonged to our institution. The review factor included administration time, total review time, and revision frequency. The revision frequency and total review time influenced the efficiency of review. Results The latent variable of reviewing was the most important factor mediating the PIs and vulnerability to IRB review approval. The local PIs moderated with genetic study and revision frequency had an impact on the review process and mediated non-approval. Conclusions Better guidance of the investigators and reviewers might improve the efficiency with which IRBs function.
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Affiliation(s)
- Dong-Sheng Tzeng
- Kaohsiung Armed Forces General Hospital, No. 2, Chung-Cheng 1st Road, Kaohsiung City, Taiwan. .,Tri-Service General Hospital Beitou Branch, Taipei City, Taiwan.
| | - Yi-Chang Wu
- Institute of Aviation and Space Medicine, National Defense Medical Center, Taipei, Taiwan.
| | - Jane-Yi Hsu
- Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung City, Taiwan.
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Prost A, Binik A, Abubakar I, Roy A, De Allegri M, Mouchoux C, Dreischulte T, Ayles H, Lewis JJ, Osrin D. Logistic, ethical, and political dimensions of stepped wedge trials: critical review and case studies. Trials 2015; 16:351. [PMID: 26278521 PMCID: PMC4538739 DOI: 10.1186/s13063-015-0837-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 07/01/2015] [Indexed: 12/24/2022] Open
Abstract
Background Three arguments are usually invoked in favour of stepped wedge cluster randomised controlled trials: the logistic convenience of implementing an intervention in phases, the ethical benefit of providing the intervention to all clusters, and the potential to enhance the social acceptability of cluster randomised controlled trials. Are these alleged benefits real? We explored the logistic, ethical, and political dimensions of stepped wedge trials using case studies of six recent evaluations. Methods We identified completed or ongoing stepped wedge evaluations using two systematic reviews. We then purposively selected six with a focus on public health in high, middle, and low-income settings. We interviewed their authors about the logistic, ethical, and social issues faced by their teams. Two authors reviewed interview transcripts, identified emerging issues through qualitative thematic analysis, reflected upon them in the context of the literature, and invited all participants to co-author the manuscript. Results Our analysis raises three main points. First, the phased implementation of interventions can alleviate problems linked to simultaneous roll-out, but also brings new challenges. Issues to consider include the feasibility of organising intervention activities according to a randomised sequence, estimating time lags in implementation and effects, and accommodating policy changes during the trial period. Second, stepped wedge trials, like parallel cluster trials, require equipoise: without it, randomising participants to a control condition, even for a short time, remains problematic. In stepped wedge trials, equipoise is likely to lie in the degree of effect, effectiveness in a specific operational milieu, and the balance of benefit and harm, including the social value of better evaluation. Third, the strongest arguments for a stepped wedge design are logistic and political rather than ethical. The design is advantageous when simultaneous roll-out is impractical and when it increases the acceptability of using counterfactuals. Conclusions The logistic convenience of phased implementation is context-dependent, and may be vitiated by the additional requirements of phasing. The potential for stepped wedge trials to enhance the social acceptability of cluster randomised trials is real, but their ethical legitimacy still rests on demonstrating equipoise and its configuration for each research question and setting.
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Affiliation(s)
- Audrey Prost
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
| | | | | | - Anjana Roy
- Public Health England (PHE), Colindale, UK.
| | - Manuela De Allegri
- Institute of Public Health, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany.
| | | | | | - Helen Ayles
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | - James J Lewis
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | - David Osrin
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
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Abstract
Today's clinical practice relies on the application of well-designed clinical research, the gold standard test of an intervention being the randomized controlled trial. Principles of the randomized control trial include emphasis on the principal research question, randomization, blinding; definitions of outcome measures, of inclusion and exclusion criteria, and of comorbid and confounding factors; enrolling an adequate sample size; planning data management and analysis; preventing challenges to trial integrity such as drop-out, drop-in, and bias. The application of pretrial planning is stressed to ensure the proper application of epidemiological principles resulting in clinical studies that are feasible and generalizable. In addition, funding strategies and trial team composition are discussed.
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Affiliation(s)
- Bryan M Curtis
- Medicine, Patient Research Centre, Health Science Centre, Memorial University of Newfoundland, 300 Prince Philip Drive, St. John's, NF, Canada, A1B 3V6,
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Minary L, Claudot F, Alla F. [Intervention research in public health. Methodological and legal aspects of collective interventions]. Presse Med 2014; 43:888-91. [PMID: 25123316 DOI: 10.1016/j.lpm.2014.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- Laetitia Minary
- Inserm, CIC-EC, CIE6, 54000 Nancy, France; CHU de Nancy, pôle S2R, épidémiologie et évaluation cliniques, 54000 Nancy, France; Université de Lorraine, université Paris Descartes, Apemac, EA4360, 54000 Nancy, France
| | - Frédérique Claudot
- Université de Lorraine, ETHOS, EA7299, 54000 Nancy, France; CHU de Nancy, pôle S2R, 54000 Nancy, France; Université de Lorraine, service de médecine légale et droit de la santé, 54000 Nancy, France
| | - François Alla
- Inserm, CIC-EC, CIE6, 54000 Nancy, France; CHU de Nancy, pôle S2R, épidémiologie et évaluation cliniques, 54000 Nancy, France; Université de Lorraine, université Paris Descartes, Apemac, EA4360, 54000 Nancy, France.
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Hyder AA, Pratt B, Ali J, Kass N, Sewankambo N. The ethics of health systems research in low- and middle-income countries: a call to action. Glob Public Health 2014; 9:1008-22. [PMID: 25104051 PMCID: PMC4198578 DOI: 10.1080/17441692.2014.931998] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The increasing conduct of health systems research (HSR) in low- and middle-income countries (LMICs) has not been matched by concurrent work to clarify the field's ethical dimensions. To begin to address this gap, a two-day workshop on the ethics of HSR in LMICs was convened at Johns Hopkins University in June 2013. Participants included health systems researchers, philosophers, lawyers, bioethicists and institutional review board members from Botswana, Uganda, the UK, USA and Zambia. Based on discussions from the workshop, the paper affirms that, while HSR in LMICs raises ethical issues in relation to constructs (i.e. consent, risk, equipoise) common to international clinical research, the nature of the issues that arise often differ between the two fields. Three salient features of HSR and the ethical considerations associated with each of them in LMICs are described to demonstrate this point. Recommendations for institutional review boards' oversight of HSR in LMICs are presented. Finally, a call is made for further action to develop thinking and guidance around the ethics of HSR in resource-poor settings.
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Affiliation(s)
- Adnan A. Hyder
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, United States
| | - Bridget Pratt
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, United States
- Nossal Institute of Global Health, The University of Melbourne, Victoria, Australia
| | - Joseph Ali
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, United States
| | - Nancy Kass
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, United States
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Oduwo E, Edwards SJL. A systematic review of factors affecting children's right to health in cluster randomized trials in Kenya. Trials 2014; 15:287. [PMID: 25027410 PMCID: PMC4223386 DOI: 10.1186/1745-6215-15-287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 07/01/2014] [Indexed: 11/10/2022] Open
Abstract
Following the South African case, Treatment Action Campaign and Others v Minister of Health and Others, the use of 'pilot' studies to investigate interventions already proven efficacious, offered free of charge to government, but confined by the government to a small part of the population, may violate children's right to health, and the negative duty on governments not to prevent access to treatment. The applicants challenged a government decision to offer Nevirapine in a few pilot sites when evidence showed Nevirapine significantly reduced HIV transmission rates and despite donor offers of a free supply. The government refused to expand access, arguing they needed to collect more information, and citing concerns about long-term hazards, side effects, resistance and inadequate infrastructure. The court ruled this violated children's right to health and asked the government to immediately expand access. Cluster randomized trials involving children are increasingly popular, and are often used to reduce 'contamination': the possibility that members of a cluster adopt behavior of other clusters. However, they raise unique issues insufficiently addressed in literature and ethical guidelines. This case provides additional crucial guidance, based on a common human rights framework, for the Kenyan government and other involved stakeholders. Children possess special rights, often represent a 'captive' group, and so motivate extra consideration. In a systematic review, we therefore investigated whether cluster trial designs are used to prevent or delay children's access to treatment in Kenya or otherwise inconsistently with children's right to health as outlined in the above case. Although we did not find state sponsored cluster trials, most had significant public sector involvement. Core obligations under children's right to health were inadequately addressed across trials. Few cluster trials reported rationale for cluster randomization, offered post- trial access or planned to implement successful interventions. A small number of trials may have unnecessarily evaluated proven interventions, offered their control arm trial conditions worse than local standards of care or evaluated interventions ostensibly worse than local standards of care. Further research is required to establish if children's right to health in cluster trials is well understood and to explain why some obligations are unmet.
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Witt CM, Aickin M, Cherkin D, Che CT, Elder C, Flower A, Hammerschlag R, Liu JP, Lao L, Phurrough S, Ritenbaugh C, Rubin LH, Schnyer R, Wayne PM, Withers SR, Zhao-Xiang B, Young J, Berman BM. Effectiveness guidance document (EGD) for Chinese medicine trials: a consensus document. Trials 2014; 15:169. [PMID: 24885146 PMCID: PMC4045891 DOI: 10.1186/1745-6215-15-169] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 04/16/2014] [Indexed: 12/04/2022] Open
Abstract
Background There is a need for more Comparative Effectiveness Research (CER) on Chinese medicine (CM) to inform clinical and policy decision-making. This document aims to provide consensus advice for the design of CER trials on CM for researchers. It broadly aims to ensure more adequate design and optimal use of resources in generating evidence for CM to inform stakeholder decision-making. Methods The Effectiveness Guidance Document (EGD) development was based on multiple consensus procedures (survey, written Delphi rounds, interactive consensus workshop, international expert review). To balance aspects of internal and external validity, multiple stakeholders, including patients, clinicians, researchers and payers were involved in creating this document. Results Recommendations were developed for “using available data” and “future clinical studies”. The recommendations for future trials focus on randomized trials and cover the following areas: designing CER studies, treatments, expertise and setting, outcomes, study design and statistical analyses, economic evaluation, and publication. Conclusion The present EGD provides the first systematic methodological guidance for future CER trials on CM and can be applied to single or multi-component treatments. While CONSORT statements provide guidelines for reporting studies, EGDs provide recommendations for the design of future studies and can contribute to a more strategic use of limited research resources, as well as greater consistency in trial design.
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Affiliation(s)
- Claudia M Witt
- Institute for Complementary and Integrative Medicine, University Hospital Zurich, Zurich, Switzerland.
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Rico-Blázquez M, Escortell-Mayor E, Del-Cura-González I, Sanz-Cuesta T, Gallego-Berciano P, de Las Casas-Cámara G, Soto-Díaz S, García-Sanz P, Harris-de-la-Vega N, Martín-Martín M, Domínguez-Pérez L, Rivera-Álvarez A, Sarrión-Bravo JA, Pérez-de-Hita C, de-Frías-Redondo M, Ferrer-Arnedo C, Hernández-Pascual M, Valdivia-Pérez A, Fariña YR. CuidaCare: effectiveness of a nursing intervention on the quality of life's caregiver: cluster-randomized clinical trial. BMC Nurs 2014; 13:2. [PMID: 24467767 PMCID: PMC3915556 DOI: 10.1186/1472-6955-13-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 01/17/2014] [Indexed: 11/28/2022] Open
Abstract
Background In Spain, family is the main source of care for dependent people. Numerous studies suggest that providing informal (unpaid) care during a prolonged period of time results in a morbidity-generating burden. Caregivers constitute a high-risk group that experiences elevated stress levels, which reduce their quality of life. Different strategies have been proposed to improve management of this phenomenon in order to minimize its impact, but definitive conclusions regarding their effectiveness are lacking. Methods/Design A community clinical trial is proposed, with a 1-year follow-up period, that is multicentric, controlled, parallel, and with randomized allocation of clusters in 20 health care centers within the Community of Madrid. The study's objective is to evaluate the effectiveness of a standard care intervention in primary health care (intervention CuidaCare) to improve the quality of life of the caregivers, measured at 0, 6, and 12 months after the intervention. One hundred and forty two subjects (71 from each group) ≥65 years, identified by the nurse as the main caregivers, and who provide consent to participate in the study will be included. The main outcome variable will be perceived quality of life as measured by the Visual Analogue Scale (VAS) of EuroQol-5D (EQ-5D). The secondary outcome variables will be EQ-5D Dimensions, EQ-5D Index, nursing diagnosis, and Zarit's test. Prognostic variables will be recorded for the dependent patient and the caregiver. The principle analysis will be done by comparing the average change in EQ-5D VAS value before and after intervention between the two groups. All statistical tests will be performed as intention-to-treat. Prognostic factors' estimates will be adjusted by mixed-effects regression models. Possible confounding or effect-modifying factors will be taken into account. Discussion Assistance for the caregiver should be integrated into primary care services. In order to do so, incorporating standard, effective interventions with relevant outcome variables such as quality of life is necessary. Community care nurses are at a privileged position to develop interventions like the proposed one. Trial registration This trial has been registered in ClinicalTrials.gov under code number NCT 01478295.
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Affiliation(s)
- Milagros Rico-Blázquez
- Unidad de Apoyo a la Investigación, Dirección Técnica de Docencia e Investigación, Gerencia Adjunta de Planificación y Calidad, Gerencia de Atención Primaria, C/ San Martín de Porres, 6 _ 5ª planta, 28035 Madrid, Spain.
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Hyder AA, Rattani A, Krubiner C, Bachani AM, Tran NT. Ethical review of health systems research in low- and middle-income countries: a conceptual exploration. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2014; 14:28-37. [PMID: 24521334 DOI: 10.1080/15265161.2013.868950] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Given that health systems research (HSR) involves different aims, approaches, and methodologies as compared to more traditional clinical trials, the ethical issues present in HSR may be unique or particularly nuanced. This article outlines eight pertinent ethical issues that are particularly salient in HSR and argues that the ethical review process should be better tailored to ensure more efficient and appropriate oversight of HSR with adequate human protections, especially in low- and middle-income countries. The eight ethical areas we discuss include the nature of intervention, types of research subjects, units of intervention and observation, informed consent, controls and comparisons, risk assessment, inclusion of vulnerable groups, and benefits of research. HSR involving human participants is necessary to ensure health systems strengthening and quality of care and to guide public policy intelligently. Health systems researchers must carefully define their intent and goals and openly clarify the values that may influence the premises and design of protocols. As new types of population-level research activities become more commonplace, it is critical that institutional review board (IRB) and research ethics committee (REC) review processes evolve to evaluate these research protocols in ways that address the nuanced features of these studies.
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Taljaard M, Chaudhry SH, Brehaut JC, Weijer C, Boruch R, Donner A, Eccles MP, McRae AD, Saginur R, Zwarenstein M, Grimshaw JM. Survey of consent practices in cluster randomized trials: improvements are needed in ethical conduct and reporting. Clin Trials 2013; 11:60-9. [PMID: 24346609 DOI: 10.1177/1740774513513658] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Informed consent procedures in cluster randomized trials (CRTs) are considerably more complicated than in individually randomized trials. In a CRT, the units of randomization, intervention, and observation may differ in a single trial; there can be multiple levels of participants (individual and cluster level); consent may be required separately for intervention and data collection; and there may be practical constraints to seeking informed consent, for example, due to cluster-level interventions or the sheer size of clusters. PURPOSE We aimed to document consent practices at individual and cluster levels, assess the adequacy of reporting consent in trial publications, and assess associations with two trial characteristics that may influence consent requirements in CRTs: presence or absence of study interventions and presence or absence of data collection procedures at individual and cluster levels. METHODS We reviewed a random sample of 300 CRTs published during 2000-2008. We sent survey questionnaires to 285 unique authors of these trials to gather detailed information about consent procedures used in each trial. RESULTS In all, 182 authors (64%) responded. Overall, 93% (95% confidence interval (CI): 88.8%-96.6%) indicated that participant consent had been sought for some aspects of the study. Consent was less frequently sought for a study intervention (70% of respondents) than for data collection (88%). More than half of the respondents (52%) indicated that consent had been sought at both cluster and individual levels. There was strong evidence for under-reporting of consent in trial publications: only 63% of all trial publications reported that informed consent had been sought for some aspect of the study. The odds ratios (ORs) summarizing the association of the two trial characteristics with cluster-level participant consent were weak (OR = 1.17, p = 0.70 for presence of cluster-level study intervention and OR = 1.54, p = 0.29 for data collection); on the other hand, the ORs summarizing the associations with individual-level consent were strong (OR = 6.2, p < 0.0001 for presence of individual-level intervention and OR = 14.7, p < 0.0001 for data collection). LIMITATIONS In all, 36% of authors did not respond to the survey; to the extent that consent practices in their trials were different than in respondents' trials, our results may be biased. CONCLUSIONS There is a need for improvements in research practices in CRTs as well as their reporting. There may be a lack of clarity about consent requirements at the cluster level in particular. With the publication of the Ottawa Statement on the Ethical Design and Conduct of Cluster Randomized Trials, researchers and research ethics committees now have access to comprehensive ethics guidelines specific to CRTs.
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Affiliation(s)
- Monica Taljaard
- aDepartment of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
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Holt TA, Fitzmaurice DA, Marshall T, Fay M, Qureshi N, Dalton ARH, Hobbs FDR, Lasserson DS, Kearley K, Hislop J, Jin J. Automated Risk Assessment for Stroke in Atrial Fibrillation (AURAS-AF)--an automated software system to promote anticoagulation and reduce stroke risk: study protocol for a cluster randomised controlled trial. Trials 2013; 14:385. [PMID: 24220602 PMCID: PMC4225760 DOI: 10.1186/1745-6215-14-385] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 10/28/2013] [Indexed: 11/10/2022] Open
Abstract
Background Patients with atrial fibrillation (AF) are at significantly increased risk of stroke. Oral anticoagulants (OACs) substantially reduce this risk, with gains seen across the spectrum of baseline risk. Despite the benefit to patients, OAC prescribing remains suboptimal in the United Kingdom (UK). We will investigate whether an automated software system, operating within primary care electronic medical records, can improve the management of AF by identifying patients eligible for OAC therapy and increasing uptake of this treatment. Methods/Design We will conduct a cluster randomised controlled trial, involving general practices using the Egton Medical Information Systems (EMIS) Web clinical system. We will randomise practices to use an electronic software tool or to continue with usual care. The tool will a) produce (and continually refresh) a list of patients with AF who are eligible for OAC therapy - practices will invite these patients to discuss therapy at the start of the trial - and b) generate electronic screen reminders in the medical records of those eligible, appearing throughout the trial. The software will run for 6 months in 23 intervention practices. A total of 23 control practices will manage their AF register in line with the usual care offered. The primary outcome is change in proportion of eligible patients with AF who have been prescribed OAC therapy after six months. Secondary outcomes are incidence of stroke, transient ischaemic attack, other major thromboembolism, major haemorrhage and reports of inappropriate OAC prescribing in the data collection sample - those deemed eligible for OACs. We will conduct a process evaluation in parallel with the randomised trial. We will use qualitative methods to examine patient and practitioner views of the intervention and its impact on primary care practice, including its time implications. Discussion AURAS-AF will investigate whether a simple intervention, using electronic primary care records, can improve OAC uptake in a high risk group for stroke. Given previous concerns about safety, especially surrounding inappropriate prescribing, we will also examine whether electronic reminders safely impact care in this clinical area. Trial registration http://ISRCTN 55722437
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Affiliation(s)
- Tim A Holt
- Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, England.
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Garrison MM, Mangione-Smith R. Cluster randomized trials for health care quality improvement research. Acad Pediatr 2013; 13:S31-7. [PMID: 24268082 DOI: 10.1016/j.acap.2013.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 07/29/2013] [Indexed: 11/15/2022]
Affiliation(s)
- Michelle M Garrison
- Seattle Children's Research Institute, Center for Child Health, Behavior and Development, Seattle, Wash; Department of Health Services, University of Washington, Seattle, Wash; Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, University of Washington, Seattle, Wash.
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Kuchinke W. Ethical concerns caused by integrative patient empowerment solutions for personalized medicine. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2013:4775-8. [PMID: 24110802 DOI: 10.1109/embc.2013.6610615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Personalized medicine that promises targeted treatments with high therapeutic effectiveness requires an unmatched degree of participation of the patient. To enable this high degree of patient empowerment, the project p-medicine developed a Patient Empowerment Tool that is part of a clinical research infrastructure consisting of data management, data warehouse, biobank access, imaging, simulation and decision support tools. Patient autonomy is enhanced by giving patients access to their data and by providing means for informed choices and consent. Because the highly integrative nature of the Patient Empowerment Tool raised ethical concerns, an ethical requirements analysis was carried out, resulting in the assignment of five ethical clusters. The one concerned with the Patient Empowerment Tool was used to identify several concerns, like the access to unfavorable information or negative diagnosis, incomprehensible risk/benefit display, and other factors that may overstress certain patients. From the ethical point of view, the user interface should contain different profiles and control mechanisms to protect the patient and to provide an adaptable and intelligent display of information, sufficient guidance and help for users from vulnerable populations as well as for patients with life threatening diseases.
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Chaudhry SH, Brehaut JC, Grimshaw JM, Weijer C, Boruch R, Donner A, Eccles MP, McRae AD, Saginur R, Skea ZC, Zwarenstein M, Taljaard M. Challenges in the research ethics review of cluster randomized trials: international survey of investigators. Clin Trials 2013; 10:257-68. [PMID: 23539109 DOI: 10.1177/1740774513475530] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cluster randomized trials (CRTs) complicate the interpretation of standard research ethics guidelines for several reasons. For one, the units of allocation, intervention, and observation often may differ within a single trial. In the absence of tailored and internationally accepted ethics guidelines for CRTs, researchers and research ethics committees have no common standard by which to judge ethically appropriate practices in CRTs. Moreover, lack of familiarity with and consideration of the unique features of the CRT design by research ethics committees may cause difficulties in the research ethics review process, and amplify problems such as variability in the requirements and decisions reached by different research ethics committees. PURPOSE We aimed to characterize research ethics review of CRTs, examine investigator experiences with the ethics review process, and assess the need for ethics guidelines for CRTs. METHODS An electronic search strategy implemented in MEDLINE was used to identify and randomly sample 300 CRTs published in English language journals from 2000 to 2008. A web-based survey with closed- and open-ended questions was administered to corresponding authors in a series of six contacts. RESULTS The survey response rate was 64%. Among 182 of 285 eligible respondents, 91% indicated that they had sought research ethics approval for the identified CRT, although only 70% respondents reported research ethics approval in the published article. Nearly one-third (31%) indicated that they have had to meet with ethics committees to explain aspects of their trials, nearly half (46%) experienced variability in the ethics review process in multijurisdictional trials, and 38% experienced negative impacts of the ethics review process on their trials, including delays in trial initiation (28%), increased costs (10%), compromised ability to recruit participants (16%), and compromised methodological quality (9%). Most respondents (74%; 95% confidence interval (CI): 67%-80%) agreed or strongly agreed that there is a need to develop ethics guidelines for CRTs, and (70%; 95% CI: 63%-77%) that ethics committees could be better informed about distinct ethical issues surrounding CRTs. LIMITATIONS Thirty-six percent of authors did not respond to the survey. Due to the absence of comparable results from a representative sample of authors of individually randomized trials, it is unclear to what extent the reported challenges result from the CRT design. CONCLUSIONS CRT investigators are experiencing challenges in the research ethics review of their trials, including excessive delays, variability in process and outcome, and imposed requirements that can have negative consequences for study conduct. Investigators identified a clear need for ethics guidelines for CRTs and education of research ethics committees about distinct ethical issues in CRTs.
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Affiliation(s)
- Shazia H Chaudhry
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
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Randomized Cluster Crossover Trials for Reliable, Efficient, Comparative Effectiveness Testing: Design of the Prevention of Arrhythmia Device Infection Trial (PADIT). Can J Cardiol 2013; 29:652-8. [DOI: 10.1016/j.cjca.2013.01.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 01/29/2013] [Accepted: 01/29/2013] [Indexed: 11/23/2022] Open
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Lutge E, Lewin S, Volmink J, Friedman I, Lombard C. Economic support to improve tuberculosis treatment outcomes in South Africa: a pragmatic cluster-randomized controlled trial. Trials 2013; 14:154. [PMID: 23714270 PMCID: PMC3680200 DOI: 10.1186/1745-6215-14-154] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 04/22/2013] [Indexed: 11/17/2022] Open
Abstract
Background Poverty undermines adherence to tuberculosis treatment. Economic support may both encourage and enable patients to complete treatment. In South Africa, which carries a high burden of tuberculosis, such support may improve the currently poor outcomes of patients on tuberculosis treatment. The aim of this study was to test the feasibility and effectiveness of delivering economic support to patients with pulmonary tuberculosis in a high-burden province of South Africa. Methods This was a pragmatic, unblinded, two-arm cluster-randomized controlled trial, where 20 public sector clinics acted as clusters. Patients with pulmonary tuberculosis in intervention clinics (n = 2,107) were offered a monthly voucher of ZAR120.00 (approximately US$15) until the completion of their treatment. Vouchers were redeemed at local shops for foodstuffs. Patients in control clinics (n = 1,984) received usual tuberculosis care. Results Intention to treat analysis showed a small but non-significant improvement in treatment success rates in intervention clinics (intervention 76.2%; control 70.7%; risk difference 5.6% (95% confidence interval: -1.2%, 12.3%), P = 0.107). Low fidelity to the intervention meant that 36.2% of eligible patients did not receive a voucher at all, 32.3% received a voucher for between one and three months and 31.5% received a voucher for four to eight months of treatment. There was a strong dose–response relationship between frequency of receipt of the voucher and treatment success (P <0.001). Conclusions Our pragmatic trial has shown that, in the real world setting of public sector clinics in South Africa, economic support to patients with tuberculosis does not significantly improve outcomes on treatment. However, the low fidelity to the delivery of our voucher meant that a third of eligible patients did not receive it. Among patients in intervention clinics who received the voucher at least once, treatment success rates were significantly improved. Further operational research is needed to explore how best to ensure the consistent and appropriate delivery of such support to those eligible to receive it. Trial registration Current Controlled Trials
ISRCTN50689131
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Affiliation(s)
- Elizabeth Lutge
- Faculty of Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, 7505, South Africa.
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Restrictive vs liberal blood transfusion for acute upper gastrointestinal bleeding: rationale and protocol for a cluster randomized feasibility trial. Transfus Med Rev 2013; 27:146-53. [PMID: 23706959 PMCID: PMC4046243 DOI: 10.1016/j.tmrv.2013.04.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 04/11/2013] [Accepted: 04/13/2013] [Indexed: 12/13/2022]
Abstract
Acute upper gastrointestinal bleeding (AUGIB) is the commonest reason for hospitalization with hemorrhage in the UK and the leading indication for transfusion of red blood cells (RBCs). Observational studies suggest an association between more liberal RBC transfusion and adverse patient outcomes, and a recent randomised trial reported increased further bleeding and mortality with a liberal transfusion policy. TRIGGER (Transfusion in Gastrointestinal Bleeding) is a pragmatic, cluster randomized trial which aims to evaluate the feasibility and safety of implementing a restrictive versus liberal RBC transfusion policy in adult patients admitted with AUGIB. The trial will take place in 6 UK hospitals, and each centre will be randomly allocated to a transfusion policy. Clinicians throughout each hospital will manage all eligible patients according to the transfusion policy for the 6-month trial recruitment period. In the restrictive centers, patients become eligible for RBC transfusion when their hemoglobin is < 8 g/dL. In the liberal centers patients become eligible for transfusion once their hemoglobin is < 10 g/dL. All clinicians will have the discretion to transfuse outside of the policy but will be asked to document the reasons for doing so. Feasibility outcome measures include protocol adherence, recruitment rate, and evidence of selection bias. Clinical outcome measures include further bleeding, mortality, thromboembolic events, and infections. Quality of life will be measured using the EuroQol EQ-5D at day 28, and the costs associated with hospitalization for AUGIB in the UK will be estimated. Consent will be sought from participants or their representatives according to patient capacity for use of routine hospital data and day 28 follow up. The study has ethical approval for conduct in England and Scotland. Results will be analysed according to a pre-defined statistical analysis plan and disseminated in peer reviewed publications to relevant stakeholders. The results of this study will inform the feasibility and design of a phase III randomized trial.
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70
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Okello G, Jones C, Bonareri M, Ndegwa SN, McHaro C, Kengo J, Kinyua K, Dubeck MM, Halliday KE, Jukes MCH, Molyneux S, Brooker SJ. Challenges for consent and community engagement in the conduct of cluster randomized trial among school children in low income settings: experiences from Kenya. Trials 2013; 14:142. [PMID: 23680181 PMCID: PMC3661351 DOI: 10.1186/1745-6215-14-142] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 04/18/2013] [Indexed: 11/10/2022] Open
Abstract
Background There are a number of practical and ethical issues raised in school-based health research, particularly those related to obtaining consent from parents and assent from children. One approach to developing, strengthening, and supporting appropriate consent and assent processes is through community engagement. To date, much of the literature on community engagement in biomedical research has concentrated on community- or hospital-based research, with little documentation, if any, of community engagement in school-based health research. In this paper we discuss our experiences of consent, assent and community engagement in implementing a large school-based cluster randomized trial in rural Kenya. Methods Data collected as part of a qualitative study investigating the acceptability of the main trial, focus group discussions with field staff, observations of practice and authors’ experiences are used to: 1) highlight the challenges faced in obtaining assent/consent; and 2) strategies taken to try to both protect participant rights (including to refuse and to withdraw) and ensure the success of the trial. Results Early meetings with national, district and local level stakeholders were important in establishing their co-operation and support for the project. Despite this support, both practical and ethical challenges were encountered during consenting and assenting procedures. Our strategy for addressing these challenges focused on improving communication and understanding of the trial, and maintaining dialogue with all the relevant stakeholders throughout the study period. Conclusions A range of stakeholders within and beyond schools play a key role in school based health trials. Community entry and information dissemination strategies need careful planning from the outset, and with on-going consultation and feedback mechanisms established in order to identify and address concerns as they arise. We believe our experiences, and the ethical and practical issues and dilemmas encountered, will be of interest for others planning to conduct school-based research in Africa. Trial registration National Institute of Health NCT00878007
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Affiliation(s)
- George Okello
- Health Systems Department, Kenya Medical Research Institute-Wellcome Trust Collaborative Programme, Kilifi, Kenya.
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71
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Williams RL, Stange K, Phillips WR, Acheson LS, Balasubramanian B, Bayliss EA, Ferrer RL, Gill JM. Encouraging innovation, unintended consequences, and group-level research. Ann Fam Med 2013; 11:200-2. [PMID: 23690316 PMCID: PMC3659133 DOI: 10.1370/afm.1533] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 03/23/2013] [Accepted: 03/24/2013] [Indexed: 11/09/2022] Open
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Mbawalla H, Masalu JR, Masatu M, Åstrøm AN. Changes in adolescents' oral health status following oral health promotion activities in Tanzania. Acta Odontol Scand 2013; 71:333-42. [PMID: 22563991 DOI: 10.3109/00016357.2012.680907] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the impact of oral health promotion integrated with a health promoting school (HPS) initiative on the oral health outcomes of secondary school students. MATERIALS AND METHOD Using an urban-rural stratified cluster randomized approach, the intervention was applied to secondary school students in Arusha, Tanzania. In the urban, three control (n = 315) and two intervention (n = 214) schools performed oral clinical examination and questionnaires at baseline. In rural the corresponding figures at baseline were two (n = 188) and three (n = 360) schools. After 2 years, 374 and 358 students remained in the intervention and control arms. RESULTS Mean number of decayed teeth (DT) increased in the intervention (mean score 1.0 vs 1.7, p < 0.001) and control schools (mean score 1.2 vs 1.7, p < 0.001). Mean number of teeth with plaque decreased significantly in intervention and control schools. No significant difference in caries increment and plaque decline scores was observed between groups. Mean number of teeth with bleeding decreased (0.5 vs 0.3, p < 0.05) in intervention schools, whereas no change was observed in the control schools (0.4 vs 0.5, p = 0.051). Increment in mean number of DT between baseline and follow-up was largest and smallest in students who, respectively, deteriorated and improved their plaque and bleeding scores. CONCLUSION The intervention activities did not show any effect with respect to dental caries, calculus and plaque status among the students investigated. Compared with the control group, more favorable changes in the intervention group occurred with respect to bleeding on probing, suggesting a weak but positive effect on students' oral hygiene status.
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Affiliation(s)
- Hawa Mbawalla
- Department of Clinical Dentistry, Community Dentistry, University of Bergen, Bergen, Norway
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73
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McRae AD, Bennett C, Brown JB, Weijer C, Boruch R, Brehaut J, Chaudhry S, Donner A, Eccles M, Grimshaw J, Zwarenstein M, Taljaard M. Researchers' perceptions of ethical challenges in cluster randomized trials: a qualitative analysis. Trials 2013; 14:1. [PMID: 23286245 PMCID: PMC3561139 DOI: 10.1186/1745-6215-14-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 12/18/2012] [Indexed: 11/24/2022] Open
Abstract
Background Cluster randomized trials (CRTs) pose ethical challenges for investigators and ethics committees. This study describes the views and experiences of CRT researchers with respect to: (1) ethical challenges in CRTs; (2) the ethics review process for CRTs; and (3) the need for comprehensive ethics guidelines for CRTs. Methods Descriptive qualitative analysis of interviews conducted with a purposive sample of 20 experienced CRT researchers. Results Informants expressed concern over the potential for bias that may result from requirements to obtain informed consent from research participants in CRTs. Informants suggested that the need for informed consent ought to be related to the type of intervention under study in a CRT. Informants rarely expressed concern regarding risks to research participants in CRTs, other than risks to privacy. Important issues identified in the research ethics literature, including fair subject selection and other justice issues, were not mentioned by informants. The ethics review process has had positive and negative impacts on CRT conduct. Informants stated that variability in ethics review between jurisdictions, and increasingly stringent ethics review in recent years, have hampered their ability to conduct CRTs. Many informants said that comprehensive ethics guidelines for CRTs would be helpful to researchers and research ethics committees. Conclusions Informants identified key ethical challenges in the conduct of CRTs, specifically relating to identifying subjects, seeking informed consent, and the use of gatekeepers. These data have since been used to identify topics for in-depth ethical analysis and to guide the development of comprehensive ethics guidelines for CRTs.
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Affiliation(s)
- Andrew D McRae
- Division of Emergency Medicine, University of Calgary, Foothills Medical Centre, Rm C231, 1403 - 29 Street NW, Calgary, Alberta T2N 2T9, Canada.
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DiazOrdaz K, Slowther AM, Potter R, Eldridge S. Consent processes in cluster-randomised trials in residential facilities for older adults: a systematic review of reporting practices and proposed guidelines. BMJ Open 2013; 3:bmjopen-2013-003057. [PMID: 23836761 PMCID: PMC3710983 DOI: 10.1136/bmjopen-2013-003057] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess the quality of reported consent processes of cluster-randomised trials conducted in residential facilities for older people and to explore whether the focus on improving the general conduct and reporting of cluster-randomised trials influenced the quality of conduct and reporting of ethical processes in these trials. DESIGN Systematic review of cluster-randomised trials reports, published up to the end of 2010. DATA SOURCES National Library of Medicine (Medline) via PubMed, hand-searches of BMJ, Journal of the American Medical Association, BMC Health Services Research, Age and Ageing and Journal of the American Geriatrics Society, reference search in Web of Knowledge and consultation with experts. ELIGIBILITY FOR SELECTING STUDIES Published cluster-randomised trials where the unit of randomisation is a part or the whole of a residential facility for older people, without language or year of publication restrictions. RESULTS We included 73 trials. Authors reported ethical approval in 59, obtaining individual consent in 51, and using proxies for this consent in 37, but the process to assess residents' capacity to consent was clearly reported in only eight. We rated only six trials high for the quality of consent processes. We considered that individual informed consent could have been waived legitimately in 14 of 22 trials not reporting obtaining consent. The proportions reporting ethical approval and quality of consent processes were higher in recent trials. CONCLUSIONS Recently published international recommendations regarding ethical conduct in cluster-randomised trials are much needed. In relation to consent processes when cognitively impaired individuals are included in these trials, we provide a six-point checklist and recommend the minimum information to be reported. Those who lack capacity in trials with complex designs should be afforded the same care in relation to consent as competent adults in trials with simpler designs.
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Affiliation(s)
- Karla DiazOrdaz
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Anne-Marie Slowther
- Warwick Clinical Trials Unit, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Rachel Potter
- Warwick Clinical Trials Unit, Warwick Medical School, The University of Warwick, Coventry, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
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Effectiveness Guidance Document (EGD) for acupuncture research - a consensus document for conducting trials. Altern Ther Health Med 2012; 12:148. [PMID: 22953730 PMCID: PMC3495216 DOI: 10.1186/1472-6882-12-148] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 08/31/2012] [Indexed: 11/17/2022]
Abstract
Background There is a need for more Comparative Effectiveness Research (CER) to strengthen the evidence base for clinical and policy decision-making. Effectiveness Guidance Documents (EGD) are targeted to clinical researchers. The aim of this EGD is to provide specific recommendations for the design of prospective acupuncture studies to support optimal use of resources for generating evidence that will inform stakeholder decision-making. Methods Document development based on multiple systematic consensus procedures (written Delphi rounds, interactive consensus workshop, international expert review). To balance aspects of internal and external validity, multiple stakeholders including patients, clinicians and payers were involved. Results Recommendations focused mainly on randomized studies and were developed for the following areas: overall research strategy, treatment protocol, expertise and setting, outcomes, study design and statistical analyses, economic evaluation, and publication. Conclusion The present EGD, based on an international consensus developed with multiple stakeholder involvement, provides the first systematic methodological guidance for future CER on acupuncture.
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Dowdy DW, Gounder CR, Corbett EL, Ngwira LG, Chaisson RE, Merritt MW. The ethics of testing a test: randomized trials of the health impact of diagnostic tests for infectious diseases. Clin Infect Dis 2012; 55:1522-6. [PMID: 22918990 DOI: 10.1093/cid/cis736] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
In the last decade, many new rapid diagnostic tests for infectious diseases have been developed. In general, these new tests are developed with the intent to optimize feasibility and population health, not accuracy alone. However, unlike drugs or vaccines, diagnostic tests are evaluated and licensed on the basis of accuracy, not health impact (eg, reduced morbidity or mortality). Thus, these tests are sometimes recommended or scaled up for purposes of improving population health without randomized evidence that they do so. We highlight the importance of randomized trials to evaluate the health impact of novel diagnostics and note that such trials raise distinctive ethical challenges of equipoise, equity, and informed consent. We discuss the distinction between equipoise for patient-important outcomes versus diagnostic accuracy, the equity implications of evaluating health impact of diagnostics under routine conditions, and the importance of offering reasonable choices for informed consent in diagnostic trials.
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Affiliation(s)
- David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.
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Lim AYN, Shen L, Tan CH, Lateef A, Lau TC, Teng GG. Achieving treat to target in gout: a clinical practice improvement project. Scand J Rheumatol 2012; 41:450-7. [DOI: 10.3109/03009742.2012.689325] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Gallo A, Weijer C, White A, Grimshaw JM, Boruch R, Brehaut JC, Donner A, Eccles MP, McRae AD, Saginur R, Zwarenstein M, Taljaard M. What is the role and authority of gatekeepers in cluster randomized trials in health research? Trials 2012; 13:116. [PMID: 22834691 PMCID: PMC3443001 DOI: 10.1186/1745-6215-13-116] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 07/26/2012] [Indexed: 11/23/2022] Open
Abstract
This article is part of a series of papers examining ethical issues in cluster randomized trials (CRTs) in health research. In the introductory paper in this series, we set out six areas of inquiry that must be addressed if the CRT is to be set on a firm ethical foundation. This paper addresses the sixth of the questions posed, namely, what is the role and authority of gatekeepers in CRTs in health research? ‘Gatekeepers’ are individuals or bodies that represent the interests of cluster members, clusters, or organizations. The need for gatekeepers arose in response to the difficulties in obtaining informed consent because of cluster randomization, cluster-level interventions, and cluster size. In this paper, we call for a more restrictive understanding of the role and authority of gatekeepers. Previous papers in this series have provided solutions to the challenges posed by informed consent in CRTs without the need to invoke gatekeepers. We considered that consent to randomization is not required when cluster members are approached for consent at the earliest opportunity and before any study interventions or data-collection procedures have started. Further, when cluster-level interventions or cluster size means that obtaining informed consent is not possible, a waiver of consent may be appropriate. In this paper, we suggest that the role of gatekeepers in protecting individual interests in CRTs should be limited. Generally, gatekeepers do not have the authority to provide proxy consent for cluster members. When a municipality or other community has a legitimate political authority that is empowered to make such decisions, cluster permission may be appropriate; however, gatekeepers may usefully protect cluster interests in other ways. Cluster consultation may ensure that the CRT addresses local health needs, and is conducted in accord with local values and customs. Gatekeepers may also play an important role in protecting the interests of organizations, such as hospitals, nursing homes, general practices, and schools. In these settings, permission to access the organization relies on resource implications and adherence to institutional policies.
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Affiliation(s)
- Antonio Gallo
- Rotman Institute of Philosophy, University of Western Ontario, London, ON N6A 5B8, Canada
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79
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Nicholls SG, Brehaut J, Saginur R. Social science and ethics review: A question of practice not principle. RESEARCH ETHICS 2012. [DOI: 10.1177/1747016112445435] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In his article ‘The case against ethics review in the social sciences’, Schrag asserts that the social sciences should not be subject to ethical review. He recounts a number of examples where ethical review has seemingly failed. He further suggests some alternative models for dealing with ethical review in the social sciences. Finally, he concludes, and we concur, that there is a lack of empirical evidence as to the benefit of research ethics review.
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Weijer C, Grimshaw JM, Eccles MP, McRae AD, White A, Brehaut JC, Taljaard M. The Ottawa Statement on the Ethical Design and Conduct of Cluster Randomized Trials. PLoS Med 2012; 9:e1001346. [PMID: 23185138 PMCID: PMC3502500 DOI: 10.1371/journal.pmed.1001346] [Citation(s) in RCA: 191] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The Ottawa Ethics of Cluster Trials Consensus Group sets out 15 recommendations for the ethical design and conduct of cluster randomized trials.
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Affiliation(s)
- Charles Weijer
- Rotman Institute of Philosophy, Department of Philosophy, Western University, London, Ontario, Canada.
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81
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Altman DG, Hrynaszkiewicz I, Furberg CD, Grimshaw JM, Rothwell PM. Five years of Trials. Trials 2011; 12:248. [PMID: 22112799 PMCID: PMC3254076 DOI: 10.1186/1745-6215-12-248] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 11/23/2011] [Indexed: 11/16/2022] Open
Abstract
This editorial marks the launch of a special collection of articles highlighting 'Five years of Trials' (http://www.trialsjournal.com/series/5years). The journal's achievements on its objectives since 2006 are described and some of the challenges still ahead are outlined - in particular further innovating in the reporting of trials and the publication of negative results. The other articles in this series are examples of where Trials has demonstrated progress on its objectives. These include the publication of raw data, extended versions of previously published trial-related articles, descriptions of 'lessons learned', negative results, and educational articles regarding ethics and reporting bias.
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Affiliation(s)
- Douglas G Altman
- Centre for Statistics in Medicine, Wolfson College Annexe, Linton Road, Oxford OX2 6UD, UK
| | | | - Curt D Furberg
- Division of Public Health Sciences, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1063, USA
| | - Jeremy M Grimshaw
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute, and Department of Medicine, University of Ottawa, 501 Smyth Road, Ottawa ON K1H 8L6, Canada
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences Level 6, West Wing John Radcliffe Hospital Headington Oxford OX3 9DU, UK
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McRae AD, Weijer C, Binik A, Grimshaw JM, Boruch R, Brehaut JC, Donner A, Eccles MP, Saginur R, White A, Taljaard M. When is informed consent required in cluster randomized trials in health research? Trials 2011; 12:202. [PMID: 21906277 PMCID: PMC3184061 DOI: 10.1186/1745-6215-12-202] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Accepted: 09/09/2011] [Indexed: 11/10/2022] Open
Abstract
This article is part of a series of papers examining ethical issues in cluster randomized trials (CRTs) in health research. In the introductory paper in this series, we set out six areas of inquiry that must be addressed if the cluster trial is to be set on a firm ethical foundation. This paper addresses the second of the questions posed, namely, from whom, when, and how must informed consent be obtained in CRTs in health research? The ethical principle of respect for persons implies that researchers are generally obligated to obtain the informed consent of research subjects. Aspects of CRT design, including cluster randomization, cluster level interventions, and cluster size, present challenges to obtaining informed consent. Here we address five questions related to consent and CRTs: How can a study proceed if informed consent is not possible? Is consent to randomization always required? What information must be disclosed to potential subjects if their cluster has already been randomized? Is passive consent a valid substitute for informed consent? Do health professionals have a moral obligation to participate as subjects in CRTs designed to improve professional practice?We set out a framework based on the moral foundations of informed consent and international regulatory provisions to address each of these questions. First, when informed consent is not possible, a study may proceed if a research ethics committee is satisfied that conditions for a waiver of consent are satisfied. Second, informed consent to randomization may not be required if it is not possible to approach subjects at the time of randomization. Third, when potential subjects are approached after cluster randomization, they must be provided with a detailed description of the interventions in the trial arm to which their cluster has been randomized; detailed information on interventions in other trial arms need not be provided. Fourth, while passive consent may serve a variety of practical ends, it is not a substitute for valid informed consent. Fifth, while health professionals may have a moral obligation to participate as subjects in research, this does not diminish the necessity of informed consent to study participation.
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Affiliation(s)
- Andrew D McRae
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, N6A 5C1, Canada
- Division of Emergency Medicine, University of Calgary, Foothills Medical Centre, 1403 29th Street NW, Calgary, AB, T2N 2T9, Canada
- Rotman Institute of Philosophy, Department of Philosophy, University of Western Ontario, London, ON, N6A 5B8, Canada
| | - Charles Weijer
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, N6A 5C1, Canada
- Rotman Institute of Philosophy, Department of Philosophy, University of Western Ontario, London, ON, N6A 5B8, Canada
- Department of Medicine, University of Western Ontario, 339 Windermere Road, London, ON, N6A 5A5, Canada
| | - Ariella Binik
- Rotman Institute of Philosophy, Department of Philosophy, University of Western Ontario, London, ON, N6A 5B8, Canada
| | - Jeremy M Grimshaw
- Rotman Institute of Philosophy, Department of Philosophy, University of Western Ontario, London, ON, N6A 5B8, Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, K1H 8L6, Canada
| | - Robert Boruch
- Graduate School of Education and Statistics Department, Wharton School, University of Pennsylvania, 3700 Walnut Street, Philadelphia, PA, 19104, USA
| | - Jamie C Brehaut
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
| | - Allan Donner
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, N6A 5C1, Canada
- Rotman Institute of Philosophy, Department of Philosophy, University of Western Ontario, London, ON, N6A 5B8, Canada
- Robarts Clinical Trials, Robarts Research Institute, London, ON, N6A 5K8, Canada
| | - Martin P Eccles
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Raphael Saginur
- Department of Medicine, University of Ottawa and Ottawa Hospital, Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Angela White
- Rotman Institute of Philosophy, Department of Philosophy, University of Western Ontario, London, ON, N6A 5B8, Canada
| | - Monica Taljaard
- Rotman Institute of Philosophy, Department of Philosophy, University of Western Ontario, London, ON, N6A 5B8, Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
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McRae AD, Weijer C, Binik A, White A, Grimshaw JM, Boruch R, Brehaut JC, Donner A, Eccles MP, Saginur R, Zwarenstein M, Taljaard M. Who is the research subject in cluster randomized trials in health research? Trials 2011; 12:183. [PMID: 21791064 PMCID: PMC3162904 DOI: 10.1186/1745-6215-12-183] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 07/26/2011] [Indexed: 11/16/2022] Open
Abstract
This article is part of a series of papers examining ethical issues in cluster randomized trials (CRTs) in health research. In the introductory paper in this series, we set out six areas of inquiry that must be addressed if the CRT is to be set on a firm ethical foundation. This paper addresses the first of the questions posed, namely, who is the research subject in a CRT in health research? The identification of human research subjects is logically prior to the application of protections as set out in research ethics and regulation. Aspects of CRT design, including the fact that in a single study the units of randomization, experimentation, and observation may differ, complicate the identification of human research subjects. But the proper identification of human research subjects is important if they are to be protected from harm and exploitation, and if research ethics committees are to review CRTs efficiently.We examine the research ethics literature and international regulations to identify the core features of human research subjects, and then unify these features under a single, comprehensive definition of human research subject. We define a human research subject as any person whose interests may be compromised as a result of interventions in a research study. Individuals are only human research subjects in CRTs if: (1) they are directly intervened upon by investigators; (2) they interact with investigators; (3) they are deliberately intervened upon via a manipulation of their environment that may compromise their interests; or (4) their identifiable private information is used to generate data. Individuals who are indirectly affected by CRT study interventions, including patients of healthcare providers participating in knowledge translation CRTs, are not human research subjects unless at least one of these conditions is met.
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Affiliation(s)
- Andrew D McRae
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, N6A 5C1, Canada
- Division of Emergency Medicine, University of Calgary, Foothills Medical Centre, 1403 29th Street NW, Calgary, AB, T2N 2T9, Canada
- Rotman Institute of Philosophy, Department of Philosophy, University of Western Ontario, London, ON, N6A 5B8, Canada
| | - Charles Weijer
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, N6A 5C1, Canada
- Rotman Institute of Philosophy, Department of Philosophy, University of Western Ontario, London, ON, N6A 5B8, Canada
- Department of Medicine, University of Western Ontario, 339 Windermere Road, London, ON, N6A 5A5, Canada
| | - Ariella Binik
- Rotman Institute of Philosophy, Department of Philosophy, University of Western Ontario, London, ON, N6A 5B8, Canada
| | - Angela White
- Rotman Institute of Philosophy, Department of Philosophy, University of Western Ontario, London, ON, N6A 5B8, Canada
| | - Jeremy M Grimshaw
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, K1H 8L6, Canada
| | - Robert Boruch
- Graduate School of Education and Statistics Department, Wharton School, University of Pennsylvania, 3700 Walnut Street, Philadelphia, PA, 19104, USA
| | - Jamie C Brehaut
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
| | - Allan Donner
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, N6A 5C1, Canada
- Robarts Clinical Trials, Robarts Research Institute, London, ON, N6A 5K8, Canada
| | - Martin P Eccles
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Raphael Saginur
- Department of Medicine, University of Ottawa and Ottawa Hospital, Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Merrick Zwarenstein
- Centre for Health Services Sciences, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
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Binik A, Weijer C, McRae AD, Grimshaw JM, Boruch R, Brehaut JC, Donner A, Eccles MP, Saginur R, Taljaard M, Zwarenstein M. Does clinical equipoise apply to cluster randomized trials in health research? Trials 2011; 12:118. [PMID: 21569349 PMCID: PMC3113987 DOI: 10.1186/1745-6215-12-118] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 05/11/2011] [Indexed: 11/20/2022] Open
Abstract
This article is part of a series of papers examining ethical issues in cluster randomized trials (CRTs) in health research. In the introductory paper in this series, Weijer and colleagues set out six areas of inquiry that must be addressed if the cluster trial is to be set on a firm ethical foundation. This paper addresses the third of the questions posed, namely, does clinical equipoise apply to CRTs in health research? The ethical principle of beneficence is the moral obligation not to harm needlessly and, when possible, to promote the welfare of research subjects. Two related ethical problems have been discussed in the CRT literature. First, are control groups that receive only usual care unduly disadvantaged? Second, when accumulating data suggests the superiority of one intervention in a trial, is there an ethical obligation to act?In individually randomized trials involving patients, similar questions are addressed by the concept of clinical equipoise, that is, the ethical requirement that, at the start of a trial, there be a state of honest, professional disagreement in the community of expert practitioners as to the preferred treatment. Since CRTs may not involve physician-researchers and patient-subjects, the applicability of clinical equipoise to CRTs is uncertain. Here we argue that clinical equipoise may be usefully grounded in a trust relationship between the state and research subjects, and, as a result, clinical equipoise is applicable to CRTs. Clinical equipoise is used to argue that control groups receiving only usual care are not disadvantaged so long as the evidence supporting the experimental and control interventions is such that experts would disagree as to which is preferred. Further, while data accumulating during the course of a CRT may favor one intervention over another, clinical equipoise supports continuing the trial until the results are likely to be broadly convincing, often coinciding with the planned completion of the trial. Finally, clinical equipoise provides research ethics committees with formal and procedural guidelines that form an important part of the assessment of the benefits and harms of CRTs in health research.
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Affiliation(s)
- Ariella Binik
- Rotman Institute of Philosophy, Department of Philosophy, University of Western Ontario, London, ON, N6A 5B8, Canada
| | - Charles Weijer
- Rotman Institute of Philosophy, Department of Philosophy, University of Western Ontario, London, ON, N6A 5B8, Canada
- Department of Medicine, University of Western Ontario, 339 Windermere Road, London, ON, N6A 5A5, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, N6A 5C1, Canada
| | - Andrew D McRae
- Rotman Institute of Philosophy, Department of Philosophy, University of Western Ontario, London, ON, N6A 5B8, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, N6A 5C1, Canada
- Division of Emergency Medicine, University of Calgary, Foothills Medical Centre, 1403 29th Street NW, Calgary, AB, T2N 2T9, Canada
| | - Jeremy M Grimshaw
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, K1H 8L6, Canada
| | - Robert Boruch
- Graduate School of Education and Statistics Department, Wharton School, University of Pennsylvania, 3700 Walnut Street, Philadelphia, PA, 19104, USA
| | - Jamie C Brehaut
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
| | - Allan Donner
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, N6A 5C1, Canada
- Robarts Clinical Trials, Robarts Research Institute, London, ON, N6A 5K8, Canada
| | - Martin P Eccles
- Institute of Health and Society, Newcastle University, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, UK
| | - Raphael Saginur
- Department of Medicine, University of Ottawa and Ottawa Hospital, Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, K1H 8M5, Canada
| | - Merrick Zwarenstein
- Centre for Health Services Sciences, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
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Taljaard M, McRae AD, Weijer C, Bennett C, Dixon S, Taleban J, Skea Z, Eccles MP, Brehaut JC, Donner A, Saginur R, Boruch RF, Grimshaw JM. Inadequate reporting of research ethics review and informed consent in cluster randomised trials: review of random sample of published trials. BMJ 2011; 342:d2496. [PMID: 21562003 PMCID: PMC3092521 DOI: 10.1136/bmj.d2496] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2011] [Indexed: 01/07/2023]
Abstract
OBJECTIVES To investigate the extent to which authors of cluster randomised trials adhered to two basic requirements of the World Medical Association's Declaration of Helsinki and the International Committee of Medical Journal Editors' uniform requirements for manuscripts (namely, reporting of research ethics review and informed consent), to determine whether the adequacy of reporting has improved over time, and to identify characteristics of cluster randomised trials associated with reporting of ethics practices. DESIGN Review of a random sample of published cluster randomised trials from an electronic search in Medline. SETTING Cluster randomised trials in health research published in English language journals from 2000 to 2008. Study sample 300 cluster randomised trials published in 150 journals. RESULTS 77 (26%, 95% confidence interval 21% to 31%) trials failed to report ethics review. The proportion reporting ethics review increased significantly over time (P<0.001). Trials with data collection interventions at the individual level were more likely to report ethics review than were trials that used routine data sources only (79% (n=151) v 55% (23); P=0.008). Trials that accounted for clustering in the design and analysis were more likely to report ethics review. The median impact factor of the journal of publication was higher for trials that reported ethics review (3.4 v 2.3; P<0.001). 93 (31%, 26% to 36%) trials failed to report consent. Reporting of consent increased significantly over time (P<0.001). Trials with interventions targeting participants at the individual level were more likely to report consent than were trials with interventions targeting the cluster level (87% (90) v 48% (41); P<0.001). Trials with data collection interventions at the individual level were more likely to report consent than were those that used routine data sources only (78% (146) v 29% (11); P<0.001). CONCLUSIONS Reporting of research ethics protections in cluster randomised trials is inadequate. In addition to research ethics approval, authors should report whether informed consent was sought, from whom consent was sought, and what consent was for.
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Affiliation(s)
- Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON, Canada K1Y 4E9.
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