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Harris A, Gilbert F. Need for greater post-trial support for clinical trial participants assessing high-risk, irreversible treatments. JOURNAL OF MEDICAL ETHICS 2024:jme-2023-109719. [PMID: 38834240 DOI: 10.1136/jme-2023-109719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 05/18/2024] [Indexed: 06/06/2024]
Abstract
There are increasing numbers of clinical trials assessing high-risk, irreversible treatments. Trial participants should only expect knowledge gain to society, no personal therapeutic benefit. However, participation may lead to long-term harms and prevent future therapeutic options. While some discussion has occurred around post-trial access to treatments for participants who received therapeutic benefit, there are no post-trial support requirements for those suffering long-term consequences from trial participation. Participants may be left with significant medical, psychological, social, technical or financial needs. All trials will end at some point, regardless of their success. Subsequently, they should be designed to take into account the post-trial period including the impact on the ongoing health of a participant and their post-trial needs.
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Affiliation(s)
- Alex Harris
- Department of Biomedical Engineering, The University of Melbourne, Melbourne, Victoria, Australia
| | - Frederic Gilbert
- EthicsLab, School of Humanities, University of Tasmania, Hobart, Tasmania, Australia
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2
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Morain S, Largent E. Think Pragmatically: Investigators' Obligations to Patient-Subjects When Research is Embedded in Care. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:10-21. [PMID: 35435790 PMCID: PMC9576818 DOI: 10.1080/15265161.2022.2063435] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Growing interest in embedded research approaches-where research is incorporated into clinical care-has spurred numerous studies to generate knowledge relevant to the real-world needs of patients and other stakeholders. However, it also has presented ethical challenges. An emerging challenge is how to understand the nature and extent of investigators' obligations to patient-subjects. Prior scholarship on investigator duties has generally been grounded upon the premise that research and clinical care are distinct activities, bearing distinct duties. Yet this premise-and its corresponding implications-are challenged when research and clinical care are deliberately integrated. After presenting three case studies from recent pragmatic clinical trials, we identify six differences between explanatory trials and embedded research that limit the application of existing scholarship for ascertaining investigator duties. We suggest that these limitations indicate a need to account for the implications of usual care and to move beyond a narrow focus on the investigator-subject dyad, one that better reflects the team- and institution-based nature of contemporary health systems.
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3
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Garland A, Morain S, Sugarman J. Do Clinicians Have a Duty to Participate in Pragmatic Clinical Trials? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:22-32. [PMID: 36449269 PMCID: PMC10355327 DOI: 10.1080/15265161.2022.2146784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Clinicians have good moral and professional reasons to contribute to pragmatic clinical trials (PCTs). We argue that clinicians have a defeasible duty to participate in this research that takes place in usual care settings and does not involve substantive deviation from their ordinary care practices. However, a variety of countervailing reasons may excuse clinicians from this duty in particular cases. Yet because there is a moral default in favor of participating, clinicians who wish to opt out of this research must justify their refusal. Reasons to refuse include that the trial is badly designed in some way, that the trial activities will violate the clinician's conscience, or that the trial will impose excessive burdens on the clinician.
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4
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Clapp JT, Dinh C, Hsu M, Neuman MD. Clinical reasoning in pragmatic trial randomization: a qualitative interview study. Trials 2023; 24:431. [PMID: 37365614 PMCID: PMC10294416 DOI: 10.1186/s13063-023-07445-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/08/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Pragmatic trials, because they study widely used treatments in settings of routine practice, require intensive participation from clinicians who determine whether patients can be enrolled. Clinicians are often conflicted between their therapeutic obligation to patients and their willingness to enroll them in trials in which treatments are randomly determined and thus potentially suboptimal. Refusal to enroll eligible patients can hinder trial completion and damage generalizability. In order to help evaluate and mitigate clinician refusal, this qualitative study examined how clinicians reason about whether to randomize eligible patients. METHODS We performed interviews with 29 anesthesiologists who participated in REGAIN, a multicenter pragmatic randomized trial comparing spinal and general anesthesia in hip fracture. Interviews included a chart-stimulated section in which physicians described their reasoning pertaining to specific eligible patients as well as a general semi-structured section about their views on clinical research. Guided by a constructivist grounded theory approach, we analyzed data via coding, synthesized thematic patterns using focused coding, and developed an explanation using abduction. RESULTS Anesthesiologists perceived their main clinical function as preventing peri- and intraoperative complications. In some cases, they used prototype-based reasoning to determine whether patients with contraindications should be randomized; in others, they used probabilistic reasoning. These modes of reasoning involved different types of uncertainty. In contrast, anesthesiologists expressed confidence about anesthetic options when they accepted patients for randomization. Anesthesiologists saw themselves as having a fiduciary responsibility to patients and thus did not hesitate to communicate their inclinations, even when this complicated trial recruitment. Nevertheless, they voiced strong support for clinical research, stating that their involvement was mainly hindered by production pressure and workflow disruptions. CONCLUSIONS Our findings suggest that prominent ways of assessing clinician decisions about trial randomization are based on questionable assumptions about clinical reasoning. Close examination of routine clinical practice, attuned to the features of clinical reasoning we reveal here, will help both in evaluating clinicians' enrollment determinations in specific trials and in anticipating and responding to them. TRIAL REGISTRATION Regional Versus General Anesthesia for Promoting Independence After Hip Fracture (REGAIN). CLINICALTRIALS gov NCT02507505. Prospectively registered on July 24, 2015.
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Affiliation(s)
- Justin T Clapp
- Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Blockley Hall, 3rd floor, 423 Guardian Dr, PA, 19104, Philadelphia, USA.
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | | | - Monica Hsu
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Mark D Neuman
- Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Blockley Hall, 3rd floor, 423 Guardian Dr, PA, 19104, Philadelphia, USA
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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5
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Kraft SA, Porter KM, Sullivan TR, Anderson EE, Garrison NA, Baker L, Smith JM, Weiss EM. Relationship building in pediatric research recruitment: Insights from qualitative interviews with research staff. J Clin Transl Sci 2022; 6:e138. [PMID: 36590359 PMCID: PMC9794958 DOI: 10.1017/cts.2022.469] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/30/2022] [Accepted: 09/22/2022] [Indexed: 12/28/2022] Open
Abstract
Introduction Clinical research staff play a critical role in recruiting families for pediatric research, but their views are not well described. We aimed to describe how pediatric research staff build trusting research relationships with patients and their families. Methods We interviewed research staff at one pediatric research institution and its affiliated academic medical center between November 2020 and February 2021. Staff were eligible if they conducted participant recruitment, consent, and/or enrollment for clinical research. We developed our semi-structured interview guide based on a framework for trusting researcher-community partnerships. Results We interviewed 28 research staff, with a median age of 28 years (range 22-50) and a median of 5 years of experience (range 1-29). Interviewees identified factors relevant to relationship building across three levels: the individual staff member, the relational interaction with the family, and the institutional or other structural backdrop. Individual factors included how staff developed recruitment skills, their perceived roles, and their personal motivations. Relational factors spanned four stages of recruitment: before the approach, forming an initial connection with a family, building the connection, and following up. Structural factors were related to access and diversity, clinical interactions, and the COVID-19 pandemic. Conclusions Research staff discussed tensions and supports with various actors, challenges with the integration of research and clinical care, the importance of voluntariness for building trust, and multiple contributors to inequities in research. These findings reveal the importance of ensuring research staff have a voice in institutional policies and are supported to advocate for patients and families.
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Affiliation(s)
- Stephanie A. Kraft
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Kathryn M. Porter
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, WA, USA
| | | | - Emily E. Anderson
- Neiswanger Institute for Bioethics, Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Nanibaa’ A. Garrison
- Institute for Society and Genetics, University of California, Los Angeles, Los Angeles, CA, USA
- Institute for Precision Health, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Laura Baker
- Research Integration Hub, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Jodi M. Smith
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Research Integration Hub, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Elliott M. Weiss
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, WA, USA
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6
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James JE, Joseph G. "It's personalized, but it's still bucket based": The promise of personalized medicine vs. the reality of genomic risk stratification in a breast cancer screening trial. NEW GENETICS AND SOCIETY 2022; 41:228-253. [PMID: 36936188 PMCID: PMC10021681 DOI: 10.1080/14636778.2022.2115348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/03/2022] [Indexed: 06/15/2023]
Abstract
Adaptive pragmatic clinical trials offer an innovative approach that integrates clinical care and research. Yet, blurring the boundaries between research and clinical care raises questions about how clinicians and investigators balance their caregiving and research roles and what types of knowledge and risk assessment are most valued. This paper presents findings from an ethnographic ELSI (Ethical, Legal, Social Implications) study of an innovative clinical trial of risk-based breast cancer screening that utilizes genomics to stratify risk and recommend a breast cancer screening commensurate with the assessed risk. We argue that the trial demonstrates a fundamental tension between the promissory ideals of personalized medicine, and the reality of implementing risk stratified care on a population scale. We examine the development of a Screening Assignment Review Board in response to this tension which allows clinician-investigators to negotiate, but never fully resolve, the inherent contradiction of 'precision population screening'.
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Affiliation(s)
| | - Galen Joseph
- Department of Humanities and Social Sciences, University of California, San Francisco
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7
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Jones RD, Krenz C, Griffith KA, Spence R, Bradbury AR, De Vries R, Hawley ST, Zon R, Bolte S, Sadeghi N, Schilsky RL, Jagsi R. Patient Experiences, Trust, and Preferences for Health Data Sharing. JCO Oncol Pract 2022; 18:e339-e350. [PMID: 34855514 PMCID: PMC8932496 DOI: 10.1200/op.21.00491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Scholars have examined patients' attitudes toward secondary use of routinely collected clinical data for research and quality improvement. Evidence suggests that trust in health care organizations and physicians is critical. Less is known about experiences that shape trust and how they influence data sharing preferences. MATERIALS AND METHODS To explore learning health care system (LHS) ethics, democratic deliberations were hosted from June 2017 to May 2018. A total of 217 patients with cancer participated in facilitated group discussion. Transcripts were coded independently. Finalized codes were organized into themes using interpretive description and thematic analysis. Two previous analyses reported on patient preferences for consent and data use; this final analysis focuses on the influence of personal lived experiences of the health care system, including interactions with providers and insurers, on trust and preferences for data sharing. RESULTS Qualitative analysis identified four domains of patients' lived experiences raised in the context of the policy discussions: (1) the quality of care received, (2) the impact of health care costs, (3) the transparency and communication displayed by a provider or an insurer to the patient, and (4) the extent to which care coordination was hindered or facilitated by the interchange between a provider and an insurer. Patients discussed their trust in health care decision makers and their opinions about LHS data sharing. CONCLUSION Additional resources, infrastructure, regulations, and practice innovations are needed to improve patients' experiences with and trust in the health care system. Those who seek to build LHSs may also need to consider improvement in other aspects of care delivery.
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Affiliation(s)
| | | | | | | | | | | | - Sarah T. Hawley
- University of Michigan, Ann Arbor, MI,VA Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - Sage Bolte
- Inova Schar Cancer Institute, Fairfax, VA
| | | | | | - Reshma Jagsi
- University of Michigan, Ann Arbor, MI,Reshma Jagsi, MD, DPhil, Department of Radiation Oncology, University of Michigan, UHB2C490, SPC 5010, 1500 East Medical Center Dr, Ann Arbor, MI 48109-5010; e-mail:
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8
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Grob R, Gleason K, McLean P, McGraw S, Solomon M, Joffe S. Patients' roles in governance of learning: Results from a qualitative study of 16 learning healthcare systems. Learn Health Syst 2022; 6:e10269. [PMID: 35036551 PMCID: PMC8753297 DOI: 10.1002/lrh2.10269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/05/2021] [Accepted: 04/02/2021] [Indexed: 11/11/2022] Open
Abstract
Patient and family engagement has been identified as key to fulfilling Learning Healthcare Systems' (LHSs') promise as a model for improving clinical care, catalyzing research, and controlling costs. Little is known, however, about the state of patient engagement in the learning mission of these systems or about what governance structures and processes facilitate such engagement. Here, we report on an interview study of 99 patient and employee leaders in 16 systems. We found both variable levels of engagement and broad agreement that shared governance of learning remains a work in progress. We also identified a range of practices that can support or thwart development of an organizational culture conducive to shared governance, including transparency, capacity building, infrastructure investment, leadership, attention to diversity of patient partners, and committee structures. In LHSs with most sophisticated shared governance, both employees and patients contribute to building a democratic learning culture.
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Affiliation(s)
- Rachel Grob
- Center for Patient PartnershipsUniversity of Wisconsin‐MadisonMadisonWisconsinUSA
| | - Katharine Gleason
- Department of Medical Ethics and Health PolicyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | | | | | | | - Steven Joffe
- University of Pennsylvania, PhiladelphiaPennsylvaniaUSA
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9
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Garland A, Weinfurt K, Sugarman J. Incentives and payments in pragmatic clinical trials: Scientific, ethical, and policy considerations. Clin Trials 2021; 18:699-705. [PMID: 34766524 DOI: 10.1177/17407745211048178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pragmatic clinical trials are increasingly used to generate knowledge about real-world clinical interventions. However, they involve some distinctive ethical and regulatory challenges. In this article, we examine a set of issues related to incentives and other payments to patients in pragmatic clinical trials. Although many of the ethical concerns related to incentives and payments in explanatory trials pertain to pragmatic clinical trials, the pragmatic features may introduce additional challenges. These include those related to the risk of incentives and payments undermining the scientific validity and social value of pragmatic clinical trials, the sources of data used in pragmatic clinical trials, and when the pragmatic clinical trials are conducted under waivers of consent. Based on our examination of these matters, we offer some preliminary recommendations regarding incentives and payments in pragmatic clinical trials, recognizing that additional data and experiences are needed to refine them.
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Affiliation(s)
- Andrew Garland
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Kevin Weinfurt
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
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10
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Osborne B S M, Boniface M P H E, Messerle Forbes N P M, Jensen J. OHSU Employees' Opinions of Receipt of Clinical Care and Participation in Clinical Research at Place of Employment. Account Res 2021:1-13. [PMID: 34620012 DOI: 10.1080/08989621.2021.1989678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Academic medical centers conduct clinical research and provide patient care to the community and their workforce. Conflict may exist, as employees might expect benefits or feel pressured or coerced to participate in research studies or receive clinical care. Without evidence, some universities consider employees to be part of a vulnerable population for research consent at their institution, potentially restricting opportunities for employees to participate in clinical trials. At the same time, these universities encourage employees to receive health care at the same institution. We hypothesized that attitudes toward voluntary research participation and receipt of health care services at the site of employment are similar and favorable. To study this, we conducted a survey of employees at Oregon Health & Science University (OHSU) that asked parallel questions focusing on attitudes regarding concerns with participation in research and receipt of clinical care. We found the majority of respondents reported favorable and similar attitudes regarding employee participation in clinical care 596/688 (87%) or research 605/639 (95%) and personally comfortable with the idea (614/688 (90%) for clinical care, 582/639 (92%) for research participation). Our findings support efforts to remove barriers that restrict participation in clinical research by employees at academic medical centers.
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11
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Synofzik M, van Roon-Mom WMC, Marckmann G, van Duyvenvoorde HA, Graessner H, Schüle R, Aartsma-Rus A. Preparing n-of-1 Antisense Oligonucleotide Treatments for Rare Neurological Diseases in Europe: Genetic, Regulatory, and Ethical Perspectives. Nucleic Acid Ther 2021; 32:83-94. [PMID: 34591693 PMCID: PMC9058873 DOI: 10.1089/nat.2021.0039] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Antisense oligonucleotide (ASO) therapies present a promising disease-modifying treatment approach for rare neurological diseases (RNDs). However, the current focus is on "more common" RNDs, leaving a large share of RND patients still without prospect of disease-modifying treatments. In response to this gap, n-of-1 ASO treatment approaches are targeting ultrarare or even private variants. While highly attractive, this emerging, academia-driven field of ultimately individualized precision medicine is in need of systematic guidance and standards, which will allow global scaling of this approach. We provide here genetic, regulatory, and ethical perspectives for preparing n-of-1 ASO treatments and research programs, with a specific focus on the European context. By example of splice modulating ASOs, we outline genetic criteria for variant prioritization, chart the regulatory field of n-of-1 ASO treatment development in Europe, and propose an ethically informed classification for n-of-1 ASO treatment strategies and level of outcome assessments. To accommodate the ethical requirements of both individual patient benefit and knowledge gain, we propose a stronger integration of patient care and clinical research when developing novel n-of-1 ASO treatments: each single trial of therapy should inherently be driven to generate generalizable knowledge, be registered in a ASO treatment registry, and include assessment of generic outcomes, which allow aggregated analysis across n-of-1 trials of therapy.
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Affiliation(s)
- Matthis Synofzik
- Department of Neurodegenerative Diseases, Hertie-Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Tübingen, Germany.,Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | | | - Georg Marckmann
- Institute of Ethics, History and Theory of Medicine, Ludwig Maximilians University Munich, Munich, Germany
| | | | - Holm Graessner
- Institute of Medical Genetics and Applied Genomics, University of Tübingen, Tübingen, Germany.,Center for Rare Diseases, Tübingen, Germany
| | - Rebecca Schüle
- Department of Neurodegenerative Diseases, Hertie-Institute for Clinical Brain Research and Center of Neurology, University of Tübingen, Tübingen, Germany.,Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | - Annemieke Aartsma-Rus
- Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands
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12
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Largent EA, Hey SP, Harkins K, Hoffman AK, Joffe S, Lima JC, London AJ, Karlawish J. Ethical and Regulatory Issues for Embedded Pragmatic Trials Involving People Living with Dementia. J Am Geriatr Soc 2021; 68 Suppl 2:S37-S42. [PMID: 32589273 DOI: 10.1111/jgs.16620] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 11/29/2022]
Abstract
Embedded pragmatic clinical trials (ePCTs) present an opportunity to improve care for people living with dementia (PLWD) and their care partners, but they also generate a complex constellation of ethical and regulatory challenges. These challenges begin with participant identification. Interventions may be delivered in ways that make it difficult to identify who is a human subject and therefore who needs ethical and regulatory protections. The need for informed consent, a core human subjects protection, must be considered but can be in tension with the goals of pragmatic research design. Thus it is essential to consider whether a waiver or alteration of informed consent is justifiable. If informed consent is needed, the question arises of how it should be obtained because researchers must acknowledge the vulnerability of PLWD due in part to diminished capacity and also to increased dependence on others. Further, researchers should recognize that many sites where ePCTs are conducted will be unfamiliar with human subjects research regulations and ethics. In this report, the Regulation and Ethics Core of the National Institute on Aging Imbedded Pragmatic Alzheimer's disease (AD) and AD-related dementias (AD/ADRD) Clinical Trials (IMPACT) Collaboratory discusses key ethical and regulatory challenges for ePCTs in PLWD. A central thesis is that researchers should strive to anticipate and address these challenges early in the design of their ePCTs as a means of both ensuring compliance and advancing science. J Am Geriatr Soc 68:S37-S42, 2020.
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Affiliation(s)
- Emily A Largent
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Kristin Harkins
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Allison K Hoffman
- University of Pennsylvania Carey Law School, Philadelphia, Pennsylvania, USA
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Julie C Lima
- Department of Health Services, Policy & Practice , Brown University School of Public Health, Providence, Rhode Island, USA.,Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Alex John London
- Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Jason Karlawish
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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13
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Towards a Responsible Transition to Learning Healthcare Systems in Precision Medicine: Ethical Points to Consider. J Pers Med 2021; 11:jpm11060539. [PMID: 34200580 PMCID: PMC8229357 DOI: 10.3390/jpm11060539] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/02/2021] [Accepted: 06/02/2021] [Indexed: 12/12/2022] Open
Abstract
Learning healthcare systems have recently emerged as a strategy to continuously use experiences and outcomes of clinical care for research purposes in precision medicine. Although it is known that learning healthcare transitions in general raise important ethical challenges, the ethical ramifications of such transitions in the specific context of precision medicine have not extensively been discussed. Here, we describe three levers that institutions can pull to advance learning healthcare systems in precision medicine: (1) changing testing of individual variability (such as genes); (2) changing prescription of treatments on the basis of (genomic) test results; and/or (3) changing the handling of data that link variability and treatment to clinical outcomes. Subsequently, we evaluate how patients can be affected if one of these levers are pulled: (1) patients are tested for different or more factors than before the transformation, (2) patients receive different treatments than before the transformation and/or (3) patients’ data obtained through clinical care are used, or used more extensively, for research purposes. Based on an analysis of the aforementioned mechanisms and how these potentially affect patients, we analyze why learning healthcare systems in precision medicine need a different ethical approach and discuss crucial points to consider regarding this approach.
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14
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Morain SR, Largent EA. Public Attitudes toward Consent When Research Is Integrated into Care-Any "Ought" from All the "Is"? Hastings Cent Rep 2021; 51:22-32. [PMID: 33840104 DOI: 10.1002/hast.1242] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Research that is integrated into ongoing clinical activities holds the potential to accelerate the generation of knowledge to improve the health of individuals and populations. Yet integrating research into clinical care presents difficult ethical and regulatory challenges, including how or whether to obtain informed consent. Multiple empirical studies have explored patients' and the public's attitudes toward approaches to consent for pragmatic research. Questions remain, however, about how to use the resulting empirical data in resolving normative and policy debates and what kind of data warrants the most consideration. We recommend prioritizing data about what people consider acceptable with respect to consent for pragmatic research and data about people's informed, rather than initial, preferences on this subject. In addition, we advise caution regarding the weight given to majority viewpoints and identify circumstances when empirical data can be overridden. We argue that empirical data bolster normative arguments that alterations of consent should be the default in pragmatic research; waivers are appropriate only when the pragmatic research would otherwise be impracticable and has sufficiently high social value.
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15
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Morain SR, Kass NE, Faden RR. What Factors Predict Willingness to Join Low-Risk Pragmatic Clinical Trials? Ethics Hum Res 2021; 43:17-24. [PMID: 33463074 DOI: 10.1002/eahr.500075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Pragmatic clinical trials (PCTs) may improve the efficiency, relevance, and representativeness of research. While prior research has indicated that willingness to join a PCT is high, it is not universal among those asked in surveys exploring attitudes toward hypothetical PCTs. The objective of this study was to examine what factors predict willingness to join a hypothetical low-risk PCT comparing two blood pressure medicines. In our study, 2,618 respondents, recruited from three populations (adult patients from an academic health system, adult patients from an integrated delivery system, and adults from an online nationally representative panel), completed an online survey. Most respondents (90%) expressed willingness to participate in the hypothetical PCT. The two key predictors of expressed willingness to join low-risk PCTs were respondents' understanding of key features of PCTs, including how they differ from traditional research, and the degree of importance respondents perceived comparative research to have. Increasing awareness of the rationale for PCTs and understanding of these trials, including how they differ from explanatory trials, may increase prospective participants' willingness to contribute to this effort.
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Affiliation(s)
- Stephanie R Morain
- Assistant professor in the Center for Medical Ethics & Health Policy at Baylor College of Medicine
| | - Nancy E Kass
- Phoebe R. Berman Professor of Bioethics and Public Health at the Berman Institute of Bioethics and the Bloomberg School of Public Health at Johns Hopkins University
| | - Ruth R Faden
- Philip Franklin Wagley Professor of Biomedical Ethics at the Berman Institute of Bioethics
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Kraft SA, Porter KM, Duenas DM, Guerra C, Joseph G, Lee SSJ, Shipman KJ, Allen J, Eubanks D, Kauffman TL, Lindberg NM, Anderson K, Zepp JM, Gilmore MJ, Mittendorf KF, Shuster E, Muessig KR, Arnold B, Goddard KAB, Wilfond BS. Participant Reactions to a Literacy-Focused, Web-Based Informed Consent Approach for a Genomic Implementation Study. AJOB Empir Bioeth 2021; 12:1-11. [PMID: 32981477 PMCID: PMC7785634 DOI: 10.1080/23294515.2020.1823907] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Clinical genomic implementation studies pose challenges for informed consent. Consent forms often include complex language and concepts, which can be a barrier to diverse enrollment, and these studies often blur traditional research-clinical boundaries. There is a move toward self-directed, web-based research enrollment, but more evidence is needed about how these enrollment approaches work in practice. In this study, we developed and evaluated a literacy-focused, web-based consent approach to support enrollment of diverse participants in an ongoing clinical genomic implementation study. Methods: As part of the Cancer Health Assessments Reaching Many (CHARM) study, we developed a web-based consent approach that featured plain language, multimedia, and separate descriptions of clinical care and research activities. CHARM offered clinical exome sequencing to individuals at high risk of hereditary cancer. We interviewed CHARM participants about their reactions to the consent approach. We audio recorded, transcribed, and coded interviews using a deductively and inductively derived codebook. We reviewed coded excerpts as a team to identify overarching themes. Results: We conducted 32 interviews, including 12 (38%) in Spanish. Most (69%) enrolled without assistance from study staff, usually on a mobile phone. Those who completed enrollment in one day spent an average of 12 minutes on the consent portion. Interviewees found the information simple to read but comprehensive, were neutral to positive about the multimedia support, and identified increased access to testing in the study as the key difference from clinical care. Conclusions: This study showed that interviewees found our literacy-focused, web-based consent approach acceptable; did not distinguish the consent materials from other online study processes; and valued getting access to testing in the study. Overall, conducting empirical bioethics research in an ongoing clinical trial was useful to demonstrate the acceptability of our novel consent approach but posed practical challenges.
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Affiliation(s)
- Stephanie A Kraft
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, and Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Kathryn M Porter
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
| | - Devan M Duenas
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
| | - Claudia Guerra
- Department of Anthropology, History and Social Medicine, University of California, San Francisco, California, USA
| | - Galen Joseph
- Department of Anthropology, History and Social Medicine, University of California, San Francisco, California, USA
| | - Sandra Soo-Jin Lee
- Division of Ethics, Department of Medical Humanities and Ethics, Columbia University, New York, New York, USA
| | - Kelly J Shipman
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
| | - Jake Allen
- IT (Information Technology) Department, Kaiser Permanente Northwest, Center for Health Research, Portland, Oregon, USA
| | - Donna Eubanks
- IT (Information Technology) Department, Kaiser Permanente Northwest, Center for Health Research, Portland, Oregon, USA
| | - Tia L Kauffman
- Department of Translational and Applied Genomics, Kaiser Permanente Northwest, Center for Health Research, Portland, Oregon, USA
| | - Nangel M Lindberg
- Department of Translational and Applied Genomics, Kaiser Permanente Northwest, Center for Health Research, Portland, Oregon, USA
| | | | - Jamilyn M Zepp
- Department of Translational and Applied Genomics, Kaiser Permanente Northwest, Center for Health Research, Portland, Oregon, USA
| | - Marian J Gilmore
- Department of Translational and Applied Genomics, Kaiser Permanente Northwest, Center for Health Research, Portland, Oregon, USA
| | - Kathleen F Mittendorf
- Department of Translational and Applied Genomics, Kaiser Permanente Northwest, Center for Health Research, Portland, Oregon, USA
| | - Elizabeth Shuster
- Research Data and Analysis Center, Kaiser Permanente Northwest, Center for Health Research, Portland, Oregon, USA
| | - Kristin R Muessig
- Department of Translational and Applied Genomics, Kaiser Permanente Northwest, Center for Health Research, Portland, Oregon, USA
| | - Briana Arnold
- Department of Translational and Applied Genomics, Kaiser Permanente Northwest, Center for Health Research, Portland, Oregon, USA
| | - Katrina A B Goddard
- Department of Translational and Applied Genomics, Kaiser Permanente Northwest, Center for Health Research, Portland, Oregon, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, and Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
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Jones RD, Krenz C, Griffith KA, Spence R, Bradbury AR, De Vries R, Hawley ST, Zon R, Bolte S, Sadeghi N, Schilsky RL, Jagsi R. Governance of a Learning Health Care System for Oncology: Patient Recommendations. JCO Oncol Pract 2020; 17:e479-e489. [PMID: 33095694 DOI: 10.1200/op.20.00454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The learning health care system (LHS) was designed to enable real-time learning and research by harnessing data generated during patients' clinical encounters. This novel approach begets ethical questions regarding the oversight of users and uses of patient data. Understanding patients' perspectives is vitally important. MATERIALS AND METHODS We conducted democratic deliberation sessions focused on CancerLinQ, a real-world LHS. Experts presented educational content, and then small group discussions were held to elicit viewpoints. The deliberations centered around whether policies should permit or deny certain users and uses of secondary data. De-identified transcripts of the discussions were examined by using thematic analysis. RESULTS Analysis identified two thematic clusters: expectations and concerns, which seemed to inform LHS governance recommendations. Participants expected to benefit from the LHS through the advancement of medical knowledge, which they hoped would improve treatments and the quality of their care. They were concerned that profit-driven users might manipulate the data in ways that could burden or exploit patients, hinder medical decisions, or compromise patient-provider communication. It was recommended that restricted access, user fees, and penalties should be imposed to prevent users, especially for-profit entities, from misusing data. Another suggestion was that patients should be notified of potential ethical issues and included on diverse, unbiased governing boards. CONCLUSION If patients are to trust and support LHS endeavors, their concerns about for-profit users must be addressed. The ethical implementation of such systems should consist of patient representation on governing boards, transparency, and strict oversight of for-profit users.
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Affiliation(s)
| | | | | | | | | | | | - Sarah T Hawley
- University of Michigan, Ann Arbor, MI.,Veterans Administration Ann Arbor Healthcare System, Ann Arbor, MI
| | - Robin Zon
- Michiana Hematology-Oncology, Mishawaka, IN
| | - Sage Bolte
- Inova Schar Cancer Institute, Fairfax, VA
| | - Navid Sadeghi
- University of Texas Southwestern Medical Center, Dallas, TX
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Sabin JE, Cocoros NM, Garcia CJ, Goldsack JC, Haynes K, Lin ND, McCall D, Nair V, Pokorney SD, McMahill-Walraven CN, Granger CB, Platt R. Bystander Ethics and Good Samaritanism: A Paradox for Learning Health Organizations. Hastings Cent Rep 2020; 49:18-26. [PMID: 31429964 DOI: 10.1002/hast.1031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In 2012, a U.S. Institute of Medicine report called for a different approach to health care: "Left unchanged, health care will continue to underperform; cause unnecessary harm; and strain national, state, and family budgets." The answer, they suggested, would be a "continuously learning" health system. Ethicists and researchers urged the creation of "learning health organizations" that would integrate knowledge from patient-care data to continuously improve the quality of care. Our experience with an ongoing research study on atrial fibrillation-a trial known as IMPACT-AFib-gave us some insight into one of the challenges that will have to be dealt with in creating these organizations. Although the proposed educational intervention study placed no restrictions on what providers and health plans could do, the oversight team argued that the ethical principle of beneficence did not allow the researchers to be "bystanders" in relation to a control group receiving suboptimal care. In response, the researchers designed a "workaround" that allowed the project to go forward. We believe the experience suggests that what we call "bystander ethics" will create challenges for the kinds of quality improvement research that LHOs are designed to do.
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Asch DA, Joffe S, Bierer BE, Greene SM, Lieu TA, Platt JE, Whicher D, Ahmed M, Platt R. Rethinking ethical oversight in the era of the learning health system. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100462. [PMID: 32992106 DOI: 10.1016/j.hjdsi.2020.100462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/21/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
Opportunities to advance science increasingly arise through investigations embedded within routine clinical practice in the form of learning health systems. Such activities challenge conventional approaches to research regulation that have not caught up with those opportunities, often imposing burdens generalized from riskier research. We analyze the rules and conventions in the US, demonstrating how even those rules are compatible with a much more flexible approach to participant risk, institutional oversight, participant consent, and disclosure for low-risk learning activities in all jurisdictions.
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Affiliation(s)
- David A Asch
- University of Pennsylvania, Philadelphia, PA, USA; Cpl Michael J Crescenz VA Medical Center, Philadelphia, PA, USA.
| | - Steven Joffe
- University of Pennsylvania, Philadelphia, PA, USA
| | - Barbara E Bierer
- Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - Tracy A Lieu
- Kaiser Permanente Northern California, The Permanente Medical Group, Oakland, CA, USA
| | - Jodyn E Platt
- University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | - Richard Platt
- Harvard Medical School, Boston, MA, USA; Harvard Pilgrim Health Care Institute, Boston, MA, USA
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Ethical conflicts in translational genetic research: lessons learned from the eMERGE-III experience. Genet Med 2020; 22:1667-1672. [PMID: 32555418 PMCID: PMC7521988 DOI: 10.1038/s41436-020-0863-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/29/2020] [Accepted: 05/31/2020] [Indexed: 01/03/2023] Open
Abstract
PURPOSE The Electronic Medical Records and Genomics (eMERGE) Consortium integrated biorepository-based research with electronic health records (EHR) to return results from large-scale genetic tests to participants and uploaded those data into the EHR. This article explores the ethical issues investigators encountered in that process. METHODS We conducted in-depth, semistructured interviews with study personnel of the eMERGE-III Consortium sites that returned results. RESULTS We discuss major ethical issues that arose while attempting to return research results from the eMERGE Consortium to individual participants. These included difficulties recontacting those participants who had not explicitly consented to such and disclosing results to many participants with insufficient infrastructure and staff. Investigators reported being driven by a supererogatory clinical impulse. CONCLUSION All these issues ultimately derive from ethical conflicts inherent to translational work being done at the interface of research and clinical care. A critical rethinking of this divide is important, but infrastructural support for such work is necessary for an ethically sound rollout of large-scale genetic testing.
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21
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Kim J, Kassels AC, Costin NI, Schmidt H. Remote monitoring of medication adherence and patient and industry responsibilities in a learning health system. JOURNAL OF MEDICAL ETHICS 2020; 46:386-391. [PMID: 32366704 DOI: 10.1136/medethics-2019-105667] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 02/10/2020] [Accepted: 02/24/2020] [Indexed: 06/11/2023]
Abstract
A learning health system (LHS) seeks to establish a closer connection between clinical care and research and establishes new responsibilities for healthcare providers as well as patients. A new set of technological approaches in medication adherence monitoring can potentially yield valuable data within an LHS, and raises the question of the scope and limitations of patients' responsibilities to use them. We argue here that, in principle, it is plausible to suggest that patients have a prima facie obligation to use novel adherence monitors. However, the strength of the obligations depends considerably on the extent to which data that adherence monitors generate are, in fact, used to further the goals of LHSs. The way in which data ownership is structured in the USA poses a considerable challenge here, while the European Union framework offers a more promising alternative.
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Affiliation(s)
- Junhewk Kim
- Dental Education Research Center, College of Dentistry, Yonsei University, Seoul, Seodaemun-gu, Republic of Korea
| | - Austin Connor Kassels
- Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- School of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nathaniel Isaac Costin
- Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Hackensack Meridian School of Medicine, Seton Hall University, Nutley, New Jersey, USA
| | - Harald Schmidt
- Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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22
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Largent EA, Morain SR. From preferences to policies? Considerations when incorporating empirical ethics findings into research policymaking. JOURNAL OF MEDICAL ETHICS 2020; 46:378-379. [PMID: 32457201 DOI: 10.1136/medethics-2020-106184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/10/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Emily A Largent
- Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stephanie R Morain
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
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23
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Morain SR. Ostriches and Obligations: Ethical Challenges Facing Research on Usual Care. Hastings Cent Rep 2020; 49:28-30. [PMID: 31429957 DOI: 10.1002/hast.1033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In recent years, a robust body of scholarship has emerged that examines ethical challenges facing the learning health organization model. In "Bystander Ethics and Good Samaritanism," James Sabin and colleagues make a valuable addition to this scholarship, identifying and exploring the important question of what researchers' obligations are to patients receiving "usual care" if "that care is seen as suboptimal." The central issue that Sabin et al. faced was whether it would be acceptable for researchers to identify patients with untreated atrial fibrillation but then assign them to a control group that would not receive education about the importance of oral anticoagulation. The authors present this challenge as an issue of "bystander ethics." To avoid being "bystanders" to identified instances of suboptimal care, the research team decided to instead identify a "delayed intervention" group for which they would not determine the members' anticoagulation status, thereby preventing them from knowing that specific patients met the criteria for oral anticoagulants but were not using them. This "workaround" approach strikes me as disingenuous.
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Abstract
In this issue of the Hastings Center Report, James Sabin and his colleagues ask what responsibility investigators in a learning health organization have to patients when research-particularly research of which patients might be unaware-illuminates problematic aspects of the patients' care. Sabin and his colleagues were confronted by this question in the midst of designing a randomized controlled trial that sought to determine if an educational intervention targeted at patients with atrial fibrillation and their clinicians reduces underuse of oral anticoagulants. Worried about harm that might befall patients in the control group and fearing that they would be negligent bystanders if they knew these patients were at risk and did nothing, the investigators adopted a "workaround." But the "workaround," I suggest, was not a solution to the negligent bystander problem. Nor was it a solution to the problem as I would alternatively frame it-how to address instances of suboptimal patient care identified through research within learning health organizations.
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Raspa M, Moultrie R, Wagner L, Edwards A, Andrews S, Frisch MK, Turner-Brown L, Wheeler A. Ethical, Legal, and Social Issues Related to the Inclusion of Individuals With Intellectual Disabilities in Electronic Health Record Research: Scoping Review. J Med Internet Res 2020; 22:e16734. [PMID: 32436848 PMCID: PMC7273235 DOI: 10.2196/16734] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/17/2020] [Accepted: 02/22/2020] [Indexed: 01/31/2023] Open
Abstract
Background Data from electronic health records (EHRs) are increasingly used in the field of genetic research to further precision medicine initiatives. However, many of these efforts exclude individuals with intellectual disabilities, which often stem from genetic conditions. To include this important subpopulation in EHR research, important ethical, legal, and social issues should be considered. Objective The goal of this study was to review prior research to better understand what ethical, legal, and social issues may need further investigation when considering the research use of EHRs for individuals with genetic conditions that may result in intellectual disability. This information will be valuable in developing methods and best practices for involving this group in research given they are considered a vulnerable population that may need special research protections. Methods We conducted a scoping review to examine issues related to the use of EHRs for research purposes and those more broadly associated with genetic research. The initial search yielded a total of 460 unique citations. We used an evaluative coding process to determine relevancy for inclusion. Results This approach resulted in 59 articles in the following areas: informed consent, privacy and security, return of results, and vulnerable populations. The review included several models of garnering informed consent in EHR or genetic research, including tiered or categorical, blanket or general, open, and opt-out models. Second, studies reported on patients’ concerns regarding the privacy and security of EHR or genetic data, such as who has access, type of data use in research, identifiability, and risks associated with privacy breach. The literature on return of research results using biospecimens examined the dissension in the field, particularly when sharing individualized genetic results. Finally, work involving vulnerable populations highlighted special considerations when conducting EHR or genetic research. Conclusions The results frame important questions for researchers to consider when designing EHR studies, which include individuals with intellectual disabilities, including appropriate safeguards and protections.
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Affiliation(s)
- Melissa Raspa
- RTI International, Research Triangle Park, NC, United States
| | | | - Laura Wagner
- RTI International, Research Triangle Park, NC, United States
| | - Anne Edwards
- RTI International, Research Triangle Park, NC, United States
| | - Sara Andrews
- RTI International, Research Triangle Park, NC, United States
| | - Mary Katherine Frisch
- The University of North Carolina at Chapel Hill, TEACCH Autism Program, Chapel Hill, NC, United States
| | - Lauren Turner-Brown
- The University of North Carolina at Chapel Hill, TEACCH Autism Program, Chapel Hill, NC, United States
| | - Anne Wheeler
- RTI International, Research Triangle Park, NC, United States
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26
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Dranseika V, Piasecki J. Transparent Defaults and Consent for Participation in a Learning Health Care System: An Empirical Study. J Empir Res Hum Res Ethics 2020; 15:261-270. [PMID: 32046592 DOI: 10.1177/1556264620904272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We report a preregistered study that was designed to answer three questions about using transparent defaults to increase participation in a hypothetical learning health care system. Do default options influence consent to participate in learning activities within a learning health care system? Does transparency about default options decrease the effect of the defaults? Do people reconsider their choice of participation once they are informed about the defaults applied? In our study, application of the defaults did not have influence on rates of consent, nor did transparency about defaults have an effect on the rates of consent. Participants were also not likely to change their choice after being informed that defaults were applied to their previous choice. In general, our study raises doubts that defaults (both covert and transparent) can be used as an effective means in significantly increasing participation in learning health care systems.
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Affiliation(s)
- Vilius Dranseika
- Department of Philosophy and Bioethics, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland.,Vilnius University, Lithuania
| | - Jan Piasecki
- Department of Philosophy and Bioethics, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
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Factors influencing harmonized health data collection, sharing and linkage in Denmark and Switzerland: A systematic review. PLoS One 2019; 14:e0226015. [PMID: 31830124 PMCID: PMC6907832 DOI: 10.1371/journal.pone.0226015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction The digitalization of medicine has led to a considerable growth of heterogeneous health datasets, which could improve healthcare research if integrated into the clinical life cycle. This process requires, amongst other things, the harmonization of these datasets, which is a prerequisite to improve their quality, re-usability and interoperability. However, there is a wide range of factors that either hinder or favor the harmonized collection, sharing and linkage of health data. Objective This systematic review aims to identify barriers and facilitators to health data harmonization—including data sharing and linkage—by a comparative analysis of studies from Denmark and Switzerland. Methods Publications from PubMed, Web of Science, EMBASE and CINAHL involving cross-institutional or cross-border collection, sharing or linkage of health data from Denmark or Switzerland were searched to identify the reported barriers and facilitators to data harmonization. Results Of the 345 projects included, 240 were single-country and 105 were multinational studies. Regarding national projects, a Swiss study reported on average more barriers and facilitators than a Danish study. Barriers and facilitators of a technical nature were most frequently reported. Conclusion This systematic review gathered evidence from Denmark and Switzerland on barriers and facilitators concerning data harmonization, sharing and linkage. Barriers and facilitators were strictly interrelated with the national context where projects were carried out. Structural changes, such as legislation implemented at the national level, were mirrored in the projects. This underlines the impact of national strategies in the field of health data. Our findings also suggest that more openness and clarity in the reporting of both barriers and facilitators to data harmonization constitute a key element to promote the successful management of new projects using health data and the implementation of proper policies in this field. Our study findings are thus meaningful beyond these two countries.
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Morain SR, Majumder MA, McGuire AL. Learning Health System - Moving from Ethical Frameworks to Practical Implementation. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2019; 47:454-458. [PMID: 31560628 DOI: 10.1177/1073110519876180] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Stephanie R Morain
- Stephanie R. Morain, M.P.H, Ph.D., is an Assistant Professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine. She received an A.B. in Biology and History, Government, and Law from Lafayette College, an M.P.H. from Columbia University, and a Ph.D. from Harvard University. Mary A. Majumder, J.D., Ph.D.,is an Associate Professor of Medicine at the Center for Medical Ethics and Health Policy, Baylor College of Medicine. She received an A.B. from Bryn Mawr College, a J.D. from Yale Law School, and a Ph.D. from Rice. Amy L. McGuire, J.D., Ph.D., is the Leon Jaworski Professor of Biomedical Ethics and Director of the Center for Medical Ethics and Health Policy at Baylor College of Medicine. She received a B.A. in psychology from the University of Pennsylvania, a J.D. from the University of Houston, and a Ph.D. from the Institute for Medical Humanities at the University of Texas Medical Branch
| | - Mary A Majumder
- Stephanie R. Morain, M.P.H, Ph.D., is an Assistant Professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine. She received an A.B. in Biology and History, Government, and Law from Lafayette College, an M.P.H. from Columbia University, and a Ph.D. from Harvard University. Mary A. Majumder, J.D., Ph.D.,is an Associate Professor of Medicine at the Center for Medical Ethics and Health Policy, Baylor College of Medicine. She received an A.B. from Bryn Mawr College, a J.D. from Yale Law School, and a Ph.D. from Rice. Amy L. McGuire, J.D., Ph.D., is the Leon Jaworski Professor of Biomedical Ethics and Director of the Center for Medical Ethics and Health Policy at Baylor College of Medicine. She received a B.A. in psychology from the University of Pennsylvania, a J.D. from the University of Houston, and a Ph.D. from the Institute for Medical Humanities at the University of Texas Medical Branch
| | - Amy L McGuire
- Stephanie R. Morain, M.P.H, Ph.D., is an Assistant Professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine. She received an A.B. in Biology and History, Government, and Law from Lafayette College, an M.P.H. from Columbia University, and a Ph.D. from Harvard University. Mary A. Majumder, J.D., Ph.D.,is an Associate Professor of Medicine at the Center for Medical Ethics and Health Policy, Baylor College of Medicine. She received an A.B. from Bryn Mawr College, a J.D. from Yale Law School, and a Ph.D. from Rice. Amy L. McGuire, J.D., Ph.D., is the Leon Jaworski Professor of Biomedical Ethics and Director of the Center for Medical Ethics and Health Policy at Baylor College of Medicine. She received a B.A. in psychology from the University of Pennsylvania, a J.D. from the University of Houston, and a Ph.D. from the Institute for Medical Humanities at the University of Texas Medical Branch
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Desmoulin-Canselier S. Patient's lived experience with DBS between medical research and care: some legal implications. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2019; 22:375-386. [PMID: 30074133 DOI: 10.1007/s11019-018-9859-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In the past 50 years, an ethical-legal boundary has been drawn between treatment and research. It is based on the reasoning that the two activities pursue different purposes. Treatment is aimed at achieving optimal therapeutic benefits for the individual patient, whereas the goal of scientific research is to increase knowledge, in the public interest. From this viewpoint, the patient's experience should be clearly distinguished from that of a participant in a clinical trial. On this premise, two parallel and mutually exclusive regimes have been established. Yet in the case of deep brain stimulation (DBS), this presentation is a poor fit, for both the patient's lived experience and medical practice and research. The frictions may be explained by the specificities of the treatment (including surgery and medical devices) and of the pathologies concerned (chronic and evolutive), and by the characteristics of the medical team implementing the treatment. These particularities challenge the dominant frame of reference in medical bioethics and cause difficulties for the current legal framework in fulfilling its dual role: to protect patients while supporting the development of innovative treatments. The dominant model is still the clinical trial for medication safety and legal requirements of drug market regulation. However, DBS forces us to reflect on a medical device that is permanently implanted in the brain by highly specialized multi-disciplinary neurosurgical teams, for the treatment of chronic evolutive diseases. These devices demand fine-tuning on a case-by-case basis and there is still a lot to discover about why DBS is effective (or not). As a result, the wall between treatment and research is osmotic: many discoveries are made incidentally, in the course of treatment. The following study begins with these observations, and suggests that we review legal provisions (especially in French and United States law) so that they are better adapted to the first-person needs and experience of the patient undergoing brain stimulation.
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Affiliation(s)
- Sonia Desmoulin-Canselier
- CNRS/Université de Nantes UMR 6297 Droit et Changement Social, Faculté de Droit et de sciences politiques, Université de Nantes, Chemin de la Censive du Tertre, Nantes, France.
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Desmoulin-Canselier S, Moutaud B. Animal Models and Animal Experimentation in the Development of Deep Brain Stimulation: From a Specific Controversy to a Multidimensional Debate. Front Neuroanat 2019; 13:51. [PMID: 31191261 PMCID: PMC6548025 DOI: 10.3389/fnana.2019.00051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/08/2019] [Indexed: 11/13/2022] Open
Abstract
In this article, we explore a specific controversy about animal experimentation and animal models in the recent history of deep brain stimulation (DBS), and we question its ramifications. DBS development intertwines clinical practice with fundamental research and stands at the crossroads of multiple legacies. We take up the various issues and controversies embedded in this rarely addressed dispute, from a standpoint that combines socio-anthropological and legal aspects. Our starting point is a debate on the role of animal experimentation in the development of DBS between Jarrod Bailey, a researcher promoting the abolition of animal experimentation, and Alim Louis Benabid, Marwan Hariz, and Mahlon DeLong, three key figures in the area of DBS and neuroscience. By clarifying the positions of the different protagonists and retracing the issues raised in these discussions, our objective is to show how this specific debate has extended from its initial space and how it provides an object of study with heuristic scope. We first present this partially polemic discussion about the history of DBS, and its link with a more general debate on the validity and use of animal models and the need for animal experiments. Then, we raise the issue of the relations and interactions between experiments on animals and on humans in the logics of biomedical innovation. The third step is to situate the discussion within the wider framework of opposition towards animal experimentation and the promotion of animal' rights. Finally, combining these interweaved issues, possible implications emerge regarding the future of DBS. We show that behind these several controversies lie the question of translational research and the model of medicine upheld by DBS. We describe how the technology contributes to blurring the lines between research (fundamental, preclinical and clinical research) and care, as well as between humans and animals as substrates and objects of knowledge. The dynamics of DBS future development might then become a point of convergence for neuroscientists and animal rights defenders' interests.
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Affiliation(s)
- Sonia Desmoulin-Canselier
- Centre National de la Recherche Scientifique (CNRS), Nantes, France
- Droit et Changement Social, UMR 6297, Université de Nantes, Nantes, France
| | - Baptiste Moutaud
- Centre National de la Recherche Scientifique (CNRS), Nantes, France
- Laboratoire d’ethnologie et de sociologie comparative, UMR 7186, Université Paris Nanterre, Nanterre, France
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Dickert NW. The Importance of Listening to Patients and to Evidence Regarding Consent for Research. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:23-25. [PMID: 31544683 DOI: 10.1080/15265161.2019.1572834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Morain SR, Joffe S, Largent EA. When Is It Ethical for Physician-Investigators to Seek Consent From Their Own Patients? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:11-18. [PMID: 30994425 DOI: 10.1080/15265161.2019.1572811] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Classic statements of research ethics advise against permitting physician-investigators to obtain consent for research participation from patients with whom they have preexisting treatment relationships. Reluctance about "dual-role" consent reflects the view that distinct normative commitments govern physician-patient and investigator-participant relationships, and that blurring the research-care boundary could lead to ethical transgressions. However, several features of contemporary research demand reconsideration of the ethics of dual-role consent. Here, we examine three arguments advanced against dual-role consent: that it creates role conflict for the physician-investigator; that it can compromise the voluntariness of the patient-participant's consent; and that it promotes therapeutic misconceptions. Although these concerns have merit in some circumstances, they are not dispositive in all cases. Rather, their force-and the ethical acceptability of dual-role consent-varies with features of the particular study. As research participation more closely approximates usual care, it becomes increasingly acceptable, or even preferable, for physicians to seek consent for research from their own patients. It is time for a more nuanced approach to dual-role consent.
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Affiliation(s)
| | - Steven Joffe
- b University of Pennsylvania Perelman School of Medicine; Children's Hospital of Philadelphia
| | - Emily A Largent
- c University of Pennsylvania Perelman School of Medicine; Leonard Davis Institute of Health Economics
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Bluhm R, Borgerson K. An Epistemic Argument for Research-Practice Integration in Medicine. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2018; 43:469-484. [PMID: 29986063 DOI: 10.1093/jmp/jhy009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Arguments in favor of greater research-practice integration in medicine have tended to be ethical, political, or pragmatic. There are good epistemic reasons to pursue greater integration, and it is important to think through these reasons in order to avoid inadvertently designing new systems in ways that replicate the epistemic elitism common within current systems. Meaningful transformation within health care is possible with close attention to all reasons in favor of greater research-practice integration, including epistemic reasons.
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Affiliation(s)
- Robyn Bluhm
- Michigan State University, East Lansing, Michigan, USA
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van der Graaf R, Dekking SA, de Vries MC, Zwaan CM, van Delden JJ. Pediatric oncology as a Learning Health System: Ethical implications for best available treatment protocols. Learn Health Syst 2018; 2:e10052. [PMID: 31245582 PMCID: PMC6508761 DOI: 10.1002/lrh2.10052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 01/12/2018] [Accepted: 01/21/2018] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Pediatric oncology is often considered as a field in which research and care are highly integrated. We believe that this integration can be seen as a so-called Learning Health System, a system in which research is considered an important means to continuously improve the practice of care. In order to substantiate our assumption of pediatric oncology as an LHS, we will analyze so-called "best available treatment protocols." These protocols always contain research elements, even if themain goal of these protocols is to treat children diagnosed with cancer. METHODS We will analyze the implications for ethical review and informed consent if these protocols had to function as exponents of pediatric oncology an LHS. RESULTS An analysis of best available treatment protocols teaches us how these protocols integrate care and research and how these protocols can be seen as exponents of a system where care and research need no longer be sharply distinct practices. DISCUSSION Further intervention in the field of pediatric oncology is essential to also meet the requirements for an ethically responsible LHS. CONCLUSION Best available treatment protocols, which combine research and care, can be seen as examples of pediatric oncology as an LHS. However, in order to prevent that research elements in these protocols will be overlooked, we will have to find new ways to accommodate for the oversight of these protocols, such as multifaceted review and risk-adapted approaches. Moreover, informed consent process must be changed in order for patients to understand how care and research are integrated in these protocols.
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Affiliation(s)
- Rieke van der Graaf
- Department of Medical HumanitiesUniversity Medical Center Utrecht Julius CenterUtrechtThe Netherlands
| | - Sara A. Dekking
- Ethics Division Department of Public HealthMinistry of Health, Welfare and SportThe HagueThe Netherlands
| | - Martine C. de Vries
- Department of Medical Ethics and Health LawLeiden University Medical CenterLeidenThe Netherlands
| | - Christian Michel Zwaan
- Department of Paediatric OncologyErasmus MC‐Sophia Children's HospitalRotterdamThe Netherlands
| | - Johannes J.M. van Delden
- Department of Medical HumanitiesUniversity Medical Center Utrecht Julius CenterUtrechtThe Netherlands
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Soofi H. Mode 2 Knowledge Production in the Context of Medical Research: A Call for Further Clarifications. JOURNAL OF BIOETHICAL INQUIRY 2018; 15:23-27. [PMID: 29230698 DOI: 10.1007/s11673-017-9822-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 07/13/2017] [Indexed: 06/07/2023]
Abstract
The traditional researcher-driven environment of medical knowledge production is losing its dominance with the expansion of, for instance, community-based participatory or participant-led medical research. Over the past few decades, sociologists of science have debated a shift in the production of knowledge from traditional discipline-based (Mode 1) to more socially embedded and transdisciplinary frameworks (Mode 2). Recently, scholars have tried to show the relevance of Mode 2 knowledge production to medical research. However, the existing literature lacks detailed clarifications on how a model of Mode 2 knowledge production can be constructed in the context of medical research. This paper calls for such further clarifications. As a heuristic means, the advocacy for a controversial experimental stem cell therapy (Stamina) is examined. It is discussed that the example cannot be considered a step towards Mode 2 medical knowledge production. Nonetheless, the example brings to the fore some complexities of medical knowledge production that need to be further examined including: (1) the shifting landscape of defining and addressing vulnerability of research participants, (2) the emerging overlap between research and practice, and (3) public health implications of revising the standard notions of quality control and accountability.
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Affiliation(s)
- Hojjat Soofi
- Alumnus of Erasmus Mundus Master of Bioethics, Katholieke Universiteit Leuven, Radboud Universiteit Nijmegen, and Università Degli Studi di Padova, Level 6, 75 Talavera Road, North Ryde, NSW, 2113, Australia.
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Piasecki J, Dranseika V, Waligora M. Should Epidemiological Studies Be Subject to Ethics Review? Public Health Ethics 2017. [DOI: 10.1093/phe/phx016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jan Piasecki
- REMEDY, Research Ethics in Medicine Study Group, Department of Philosophy and Bioethics, Faculty of Health Sciences, Jagiellonian University, Medical College
| | - Vilius Dranseika
- REMEDY, Research Ethics in Medicine Study Group, Department of Philosophy and Bioethics, Faculty of Health Sciences, Jagiellonian University, Medical College
- Department of Logic and History of Philosophy, Vilnius University
| | - Marcin Waligora
- REMEDY, Research Ethics in Medicine Study Group, Department of Philosophy and Bioethics, Faculty of Health Sciences, Jagiellonian University, Medical College
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Courtright KR, Halpern SD, Joffe S, Ellenberg SS, Karlawish J, Madden V, Gabler NB, Szymanski S, Yadav KN, Dember LM. Willingness to participate in pragmatic dialysis trials: the importance of physician decisional autonomy and consent approach. Trials 2017; 18:474. [PMID: 29020994 PMCID: PMC5637128 DOI: 10.1186/s13063-017-2217-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 09/26/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Pragmatic clinical trials embedded in routine delivery of clinical care can lead to improvements in quality of care, but often have design features that raise ethical concerns. METHODS We performed a discrete choice experiment and used conjoint analysis to assess how specific attributes of pragmatic dialysis trials influenced patients' and physicians' willingness to have their dialysis facility participate in a hypothetical trial of hypertension management. Electronic survey data were collected from 200 patients enrolled from 11 outpatient hemodialysis units and from 203 nephrologists. The three attributes studied were physicians' treatment autonomy, participants' research burden, and the approach to consent. The influence of each attribute was quantified using mixed-effects logistic regression. RESULTS Similar proportions of patients were willing to have their facilities participate in a trial with high vs. low physician autonomy (77% vs. 79%; p = 0.13) and research burden (76% vs. 80%; p = 0.06). Opt-in, opt-out, and notification-only consent approaches were acceptable to most patients (84%, 82%, and 81%, respectively), but compared to each of these consent approaches, fewer patients (66%) were willing to have their facility participate in a trial that used no notification (p < 0.001 for each 2-way comparison). Among the physicians, similar proportions were willing to participate in trials with high and low physician autonomy (61% and 61%, respectively, p = 0.96) or with low and high burden (60 and 61%, respectively, p = 0.79). However, as for the patients, the consent approach influenced trial acceptability with 77%, 69%, and 62% willing to participate using opt-in, opt-out, and notification-only, respectively, compared to no notification (36%) (p < 0.001 for each 2-way comparison). CONCLUSIONS Curtailing physician's treatment autonomy and increasing the burden associated with participation did not influence patients' or physicians' willingness to participate in the hypothetical research, suggesting that pragmatic dialysis trials are generally acceptable to patients and physicians. Both patients and physicians preferred consent approaches that include at least some level of patient notification, but the majority of patients were still willing to participate in trials that did not notify patients of the research.
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Affiliation(s)
- Katherine R. Courtright
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA USA
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA USA
| | - Steven Joffe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA USA
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Susan S. Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA USA
| | - Jason Karlawish
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA USA
- Division of Geriatrics, Department of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Vanessa Madden
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
| | - Nicole B. Gabler
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
| | - Stephanie Szymanski
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
| | - Kuldeep N. Yadav
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
| | - Laura M. Dember
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA USA
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Wolf SM, Amendola LM, Berg JS, Chung WK, Clayton EW, Green RC, Harris-Wai J, Henderson GE, Jarvik GP, Koenig BA, Lehmann LS, McGuire AL, O'Rourke P, Somkin C, Wilfond BS, Burke W. Navigating the research-clinical interface in genomic medicine: analysis from the CSER Consortium. Genet Med 2017; 20:545-553. [PMID: 28858330 PMCID: PMC5832495 DOI: 10.1038/gim.2017.137] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/11/2017] [Indexed: 11/24/2022] Open
Abstract
Purpose The Clinical Sequencing Exploratory Research (CSER) Consortium encompasses nine National Institutes of Health–funded U-award projects investigating translation of genomic sequencing into clinical care. Previous literature has distinguished norms and rules governing research versus clinical care. This is the first study to explore how genomics investigators describe and navigate the research–clinical interface. Methods A CSER working group developed a 22-item survey. All nine U-award projects participated. Descriptive data were tabulated and qualitative analysis of text responses identified themes and characterizations of the research–clinical interface. Results Survey responses described how studies approached the research–clinical interface, including in consent practices, recording results, and using a research versus clinical laboratory. Responses revealed four characterizations of the interface: clear separation between research and clinical care, interdigitation of the two with steps to maintain separation, a dynamic interface, and merging of the two. All survey respondents utilized at least two different characterizations. Although research has traditionally been differentiated from clinical care, respondents pointed to factors blurring the distinction and strategies to differentiate the domains. Conclusion These results illustrate the difficulty in applying the traditional bifurcation of research versus clinical care to translational models of clinical research, including in genomics. Our results suggest new directions for ethics and oversight.
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Affiliation(s)
- Susan M Wolf
- Law School; Medical School; Consortium on Law and Values in Health, Environment & the Life Sciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Laura M Amendola
- Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jonathan S Berg
- Departments of Genetics and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University, New York, New York, USA
| | - Ellen Wright Clayton
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert C Green
- Genetics, Department of Medicine, Brigham and Women's Hospital, Broad Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Julie Harris-Wai
- Institute for Health and Aging, University of California-San Francisco; Division of Research, Kaiser Permanente Northern California, San Francisco, California, USA
| | - Gail E Henderson
- Department of Social Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Gail P Jarvik
- Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington, USA.,Department of Genome Sciences, University of Washington, Seattle, Washington, USA
| | - Barbara A Koenig
- Program in Bioethics, Institute for Health and Aging, University of California-San Francisco, San Francisco, California, USA
| | - Lisa Soleymani Lehmann
- Veterans Administration National Center for Ethics in Health Care, Washington, DC, USA.,Harvard University, Cambridge, Massachusetts, USA
| | - Amy L McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas, USA
| | - Pearl O'Rourke
- Human Research Affairs, Partners HealthCare, Boston, Massachusetts, USA
| | - Carol Somkin
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Wylie Burke
- Medical Genetics, Department of Medicine, University of Washington, Seattle, Washington, USA.,Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
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Maddox TM, Albert NM, Borden WB, Curtis LH, Ferguson TB, Kao DP, Marcus GM, Peterson ED, Redberg R, Rumsfeld JS, Shah ND, Tcheng JE. The Learning Healthcare System and Cardiovascular Care: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e826-e857. [DOI: 10.1161/cir.0000000000000480] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The learning healthcare system uses health information technology and the health data infrastructure to apply scientific evidence at the point of clinical care while simultaneously collecting insights from that care to promote innovation in optimal healthcare delivery and to fuel new scientific discovery. To achieve these goals, the learning healthcare system requires systematic redesign of the current healthcare system, focusing on 4 major domains: science and informatics, patient-clinician partnerships, incentives, and development of a continuous learning culture. This scientific statement provides an overview of how these learning healthcare system domains can be realized in cardiovascular disease care. Current cardiovascular disease care innovations in informatics, data uses, patient engagement, continuous learning culture, and incentives are profiled. In addition, recommendations for next steps for the development of a learning healthcare system in cardiovascular care are presented.
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Kowalski CJ, Hutchinson RJ, Mrdjenovich AJ. The Ethics of Clinical Care and the Ethics of Clinical Research: Yin and Yang. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2017; 42:7-32. [DOI: 10.1093/jmp/jhw032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Cassel JB, Del Fabbro E, Arkenau T, Higginson IJ, Hurst S, Jansen LA, Poklepovic A, Rid A, Rodón J, Strasser F, Miller FG. Phase I Cancer Trials and Palliative Care: Antagonism, Irrelevance, or Synergy? J Pain Symptom Manage 2016; 52:437-45. [PMID: 27233136 DOI: 10.1016/j.jpainsymman.2016.02.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 02/06/2016] [Accepted: 02/26/2016] [Indexed: 12/19/2022]
Abstract
This article synthesizes the presentations and conclusions of an international symposium on Phase 1 oncology trials, palliative care, and ethics held in 2014. The purpose of the symposium was to discuss the intersection of three independent trends that unfolded in the past decade. First, large-scale reviews of hundreds of Phase I trials have indicated there is a relatively low risk of serious harm and some prospect of clinical benefit that can be meaningful to patients. Second, changes in the design and analysis of Phase I trials, the introduction of "targeted" investigational agents that are generally less toxic, and an increase in Phase I trials that combine two or more agents in a novel way have changed the conduct of these trials and decreased fears and apprehensions about participation. Third, the field of palliative care in cancer has expanded greatly, offering symptom management to late-stage cancer patients, and demonstrated that it is not mutually exclusive with disease-targeted therapies or clinical research. Opportunities for collaboration and further research at the intersection of Phase 1 oncology trials and palliative care are highlighted.
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Affiliation(s)
- J Brian Cassel
- Virginia Commonwealth University, Richmond, Virginia, USA.
| | | | - Tobias Arkenau
- Sarah Cannon Research Institute and University College London, London, United Kingdom
| | - Irene J Higginson
- Cicely Saunders Institute, King's College London, London, United Kingdom
| | - Samia Hurst
- Institut d'éthique biomedicale, Centre médical universitaire, Geneva, Switzerland
| | - Lynn A Jansen
- Oregon Health and Science University, Portland, Oregon, USA
| | | | - Annette Rid
- King's College London, London, United Kingdom
| | - Jordi Rodón
- Vall d'Hebron Institut d'Oncologia, Barcelona, Spain
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Wendler D, Johnson R. When clinical care is like research: the need for review and consent. THEORETICAL MEDICINE AND BIOETHICS 2016; 37:193-209. [PMID: 27188333 DOI: 10.1007/s11017-016-9364-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The prevailing "segregated model" for understanding clinical research sharply separates it from clinical care and subjects it to extensive regulations and guidelines. This approach is based on the fact that clinical research relies on procedures and methods-research biopsies, blinding, randomization, fixed treatment protocols, placebos-that pose risks and burdens to participants in order to collect data that might benefit all patients. Reliance on these methods raises the potential for exploitation and unfairness, and thus points to the need for independent ethical review and more extensive informed consent. In contrast, it is widely assumed that clinical care does not raise these ethical concerns because it is designed to promote the best interests of individual patients. The segregation of clinical research from clinical care has been largely effective at protecting research participants. At the same time, this approach ignores the fact that several aspects of standard clinical care, such as clinician training and scheduling, also pose some risks and burdens to present patients for the benefit of all patients. We argue that recently proposed learning health care systems offer a way to address this concern, and better protect patients, by developing integrated review and consent procedures. Specifically, current approaches base the need for independent ethical review and more extensive informed consent on whether an activity is categorized as clinical research or clinical care. An ethically sounder approach, which could be incorporated into learning health care systems, would be to base the need for independent ethical review and more extensive informed consent on the extent to which an activity poses risks to present patients for the benefit of all patients.
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Affiliation(s)
- David Wendler
- Department of Bioethics, NIH Clinical Center, Building 10, Room 1C118, Bethesda, MD, 20892-1156, USA.
| | - Rebecca Johnson
- Department of Sociology, Princeton University, Princeton, NJ, USA
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Denburg A, Rodriguez-Galindo C, Joffe S. Clinical Trials Infrastructure as a Quality Improvement Intervention in Low- and Middle-Income Countries. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:3-11. [PMID: 27216089 DOI: 10.1080/15265161.2016.1170230] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Mounting evidence suggests that participation in clinical trials confers neither advantage nor disadvantage on those enrolled. Narrow focus on the question of a "trial effect," however, distracts from a broader mechanism by which patients may benefit from ongoing clinical research. We hypothesize that the existence of clinical trials infrastructure-the organizational culture, systems, and expertise that develop as a product of sustained participation in cooperative clinical trials research-may function as a quality improvement lever, improving the quality of care and outcomes of all patients within an institution or region independent of their individual participation in trials. We further contend that this "infrastructure effect" can yield particular benefits for patients in low- and middle-income countries (LMICs). The hypothesis of an infrastructure effect as a quality improvement intervention, if correct, justifies enhanced research capacity in LMIC as a pillar of health system development.
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Affiliation(s)
- Avram Denburg
- a The Hospital for Sick Children and McMaster University
| | | | - Steven Joffe
- c University of Pennsylvania Perelman School of Medicine
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Morain SR, Kass NE. Ethics Issues Arising in the Transition to Learning Health Care Systems: Results from Interviews with Leaders from 25 Health Systems. EGEMS (WASHINGTON, DC) 2016; 4:1212. [PMID: 27141521 PMCID: PMC4827789 DOI: 10.13063/2327-9214.1212] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION There is increased interest in transitioning to a "learning health care system" (LHCS). While this transition brings the potential for significant benefits, it also presents several ethical considerations. Identifying the ethical issues faced by institutions in this transition is critical for realizing the goals of learning health care so that these issues can be anticipated and, where possible, resolved. METHODS 29 semi-structured telephone interviews were conducted with leaders within 25 health care institutions. Respondents were recruiting using purposive sampling, targeting institutions considered as LHCS leaders. All interviews were audiorecorded and transcribed. NVIVO10 software was used to support qualitative analysis. RESULTS Respondents described seven ethical challenges: (1) ethical oversight of learning activities; (2) transparency of learning activities to patients; (3) potential tensions between improving quality and reducing costs; (4) data sharing and data management; (5) lag time between discovery and implementation; (6) transparency to patients about quality; and (7) randomization for quality improvement initiatives. DISCUSSION To move towards LHCS, several ethical considerations require further attention, including: the continued appropriateness of the research-treatment distinction; policy frameworks for privacy and data sharing; informing patients about learning activities; obligations to share data on quality; and the potential for trade-offs between quality improvement and cost control. CONCLUSION To our knowledge, this is the first project to ask leaders from health care systems committed to ongoing learning about the ethical issues they have faced in this effort. Their experiences can provide guidance on relevant ethical issues, and what might be done to resolve them.
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Affiliation(s)
| | - Nancy E Kass
- Berman Institute of Bioethics, Johns Hopkins University
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Lee SSJ, Kelley M, Cho MK, Kraft SA, James C, Constantine M, Meyer AN, Diekema D, Capron AM, Wilfond BS, Magnus D. Adrift in the Gray Zone: IRB Perspectives on Research in the Learning Health System. AJOB Empir Bioeth 2016; 7:125-134. [PMID: 27917391 DOI: 10.1080/23294515.2016.1155674] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Human subjects protection in healthcare contexts rests on the premise that a principled boundary distinguishes clinical research and clinical practice. However, growing use of evidence-based clinical practices by health systems makes it increasingly difficult to disentangle research from a wide range of clinical activities that are sometimes called "research on medical practice" (ROMP), including quality improvement activities and comparative effectiveness research. The recent growth of ROMP activities has created an ethical and regulatory gray zone with significant implications for the oversight of human subjects research. METHODS We conducted six semi-structured, open-ended focus group discussions with IRB members to understand their experiences and perspectives on ethical oversight of ROMP, including randomization of patients to standard treatments. RESULTS Our study revealed that IRB members are unclear or divided on the central questions at stake in the current policy debate over ethical oversight of ROMP: IRB members struggle to make a clear distinction between clinical research and medical practice improvement, lack consensus on when ROMP requires IRB review and oversight, and are uncertain about what constitutes incremental risk when patients are randomized to different treatments, any of which may be offered in usual care. They characterized the central challenge as a balancing act, between, on the one hand, making information fully transparent to patients and providing adequate oversight, and on the other hand, avoiding a chilling effect on the research process or harming the physician-patient relationship. CONCLUSIONS Evidence-based guidance that supports IRB members in providing adequate and effective oversight of ROMP without impeding the research process or harming the physician-patient relationship is necessary to realize the full benefits of the learning health system.
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Kraybill A, Dember LM, Joffe S, Karlawish J, Ellenberg SS, Madden V, Halpern SD. Patient and Physician Views about Protocolized Dialysis Treatment in Randomized Trials and Clinical Care. AJOB Empir Bioeth 2015; 7:106-115. [PMID: 27833931 DOI: 10.1080/23294515.2015.1111272] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Pragmatic trials comparing standard-of-care interventions may improve the quality of care for future patients, but raise ethical questions about limitations on decisional autonomy. We sought to understand how patients and physicians view and respond to these questions in the contexts of pragmatic trials and of usual clinical care. METHODS We conducted scenario-based, semi-structured interviews with 32 patients with end-stage renal disease (ESRD) receiving maintenance hemodialysis in outpatient dialysis units and with 24 nephrologists. Each participant was presented with two hypothetical scenarios in which a protocolized approach to hemodialysis treatment time was adopted for the entire dialysis unit as part of a clinical trial or a new clinical practice. RESULTS A modified grounded theory analysis revealed three major themes: 1) the value of research, 2) the effect of protocolized care on patient and physician autonomy, and 3) information exchange between patients and physicians, including the mechanism of consent. Most patients and physicians were willing to relinquish decisional autonomy and were more willing to relinquish autonomy for research purposes than in clinical care. Patients' concerns towards clinical trials were tempered by their desires for certainty for a positive outcome and for physician validation. Patients tended to believe that being informed about research was more important than the actual mechanism of consent, and most were content with being able to opt out from participating. CONCLUSIONS This qualitative study suggests the general acceptability of a pragmatic clinical trial comparing standard-of-care interventions that limits decisional autonomy for nephrologists and patients receiving hemodialysis. Future studies are needed to determine whether similar findings would emerge among other patients and providers considering other standard-of-care trials.
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Affiliation(s)
- Ashley Kraybill
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
| | | | - Steven Joffe
- Department of Medical Ethics and Health Policy, University of Pennsylvania
| | - Jason Karlawish
- Department of Medicine, University of Pennsylvania; Department of Medical Ethics and Health Policy, University of Pennsylvania; Leonard Davis Institute of Health Economics Center for Health Incentives and Behavioral Economics, at the Perelman School of Medicine, University of Pennsylvania
| | - Susan S Ellenberg
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; Department of Biostatistics and Epidemiology
| | - Vanessa Madden
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
| | - Scott D Halpern
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; Department of Medicine, University of Pennsylvania; Department of Medical Ethics and Health Policy, University of Pennsylvania; Leonard Davis Institute of Health Economics Center for Health Incentives and Behavioral Economics, at the Perelman School of Medicine, University of Pennsylvania; Department of Biostatistics and Epidemiology
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Trends in characteristics of cardiovascular clinical trials 2001-2012. Am Heart J 2015; 170:263-72. [PMID: 26299223 DOI: 10.1016/j.ahj.2015.05.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 05/12/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Efficient conduct of clinical trials is essential for the timely generation of critical medical knowledge. METHODS We systematically assessed size, duration, enrollment rates, and geographic distribution of randomized cardiovascular trials published between 2001 and 2012 in the 8 highest-impact journals in general medicine and cardiology. RESULTS Of the 1,224 trials, 27.0% were conducted in North America, 36.5% in Western Europe, and 7.7% in other countries, and 28.8% were multiregional. Trials enrolled a median of 452 patients (interquartile range 167-1,530) in 20 sites (2-76). Median duration was 2.1 (1.3-3.3) years, with an estimated enrollment rate of 1.1 (0.5-3.5) patients/site per month. Between 2001-2003 and 2009-2012, the proportion of North American trials decreased from 34.5% to 25.7% (P = .006), whereas that of multiregional trials (from 26.0% to 30.3%; P = .046) and trials conducted in other countries (from 4.6% to 10.3%; P = .012) increased. Over time, trials involved more patients (from 400 to 500 [median]; P = .032) and sites (from 20 to 22; P = .049), multiregional trials involved more countries (from 12 to 18; P = .031), and enrollment rate declined from 1.2 to 0.9 patients/site per month (P = .017). The proportion of trials meeting their primary end point ("positive") decreased from 69% to 57% (P < .001). Trials with higher enrollment rates were more likely to be positive (odds ratio 1.20 per doubling, 95% CI 1.12-1.29), as were industry-sponsored compared with government-sponsored trials (odds ratio 2.62, 95% CI 1.67-4.12). CONCLUSIONS From 2001 to 2012, cardiovascular clinical trials have become larger, more global, and less likely to meet their primary end point. Enrollment rates have declined, requiring more sites and regions.
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Anderson ML, Califf RM, Sugarman J. Ethical and regulatory issues of pragmatic cluster randomized trials in contemporary health systems. Clin Trials 2015; 12:276-86. [PMID: 25733677 PMCID: PMC4498459 DOI: 10.1177/1740774515571140] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cluster randomized trials (CRTs) randomly assign groups of individuals to examine research questions or test interventions and measure their effects on individuals. Recent emphasis on quality improvement, comparative effectiveness, and learning health systems has prompted expanded use of pragmatic CRTs in routine healthcare settings, which in turn poses practical and ethical challenges that current oversight frameworks may not adequately address. The 2012 Ottawa Statement provides a basis for considering many issues related to pragmatic CRTs but challenges remain, including some arising from the current U.S. research and healthcare regulations. In order to examine the ethical, regulatory, and practical questions facing pragmatic CRTs in healthcare settings, the National Institutes of Health (NIH) Health Care Systems Research Collaboratory convened a workshop in Bethesda, Maryland in July of 2013. Attendees included experts in clinical trials, patient advocacy, research ethics, and research regulations from academia, industry, the NIH, and other federal agencies. Workshop participants identified substantial barriers to implementing these types of CRTs, including issues related to research design, gatekeepers and governance in health systems, consent, institutional review boards, data monitoring, privacy, and special populations. We describe these barriers and suggest means for understanding and overcoming them to facilitate pragmatic CRTs in healthcare settings.
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Affiliation(s)
- Monique L Anderson
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA Duke Clinical Research Institute, Durham, NC, USA
| | - Robert M Califf
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA Duke Clinical Research Institute, Durham, NC, USA Duke Translational Medicine Institute, Duke University, Durham, NC, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Whicher D, Kass N, Saghai Y, Faden R, Tunis S, Pronovost P. The views of quality improvement professionals and comparative effectiveness researchers on ethics, IRBs, and oversight. J Empir Res Hum Res Ethics 2015; 10:132-44. [PMID: 25742674 DOI: 10.1177/1556264615571558] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Recently, there have been increasing numbers of activities labeled as either quality improvement (QI) or comparative effectiveness research (CER), both of which are designed to learn what works and what does not in routine clinical care settings. These activities can create confusion for researchers, Institutional Review Board members, and other stakeholders as they try to determine which activities or components of activities constitute clinical practices and which constitute clinical research requiring ethical oversight and informed consent. We conducted a series of semi-structured focus groups with QI and CER professionals to understand their experiences and views of the ethical and regulatory challenges that exist as well as the formal or informal practices and criteria they and their institutions use to address these issues. We found that most participants have experienced challenges related to the ethical oversight of QI and CER activities, and many believe that current regulatory criteria for distinguishing clinical practice from clinical research requiring ethical oversight are confusing. Instead, many participants described other criteria that they believe are more ethically appropriate. Many also described developing formal or informal practices at their institutions to navigate which activities require ethical oversight. However, these local solutions do not completely resolve the issues caused by the blurring of clinical practice and clinical research, raising the question of whether more foundational regulatory changes are needed.
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Affiliation(s)
| | - Nancy Kass
- Johns Hopkins University, Baltimore, MD, USA
| | | | - Ruth Faden
- Johns Hopkins University, Baltimore, MD, USA
| | - Sean Tunis
- Center for Medical Technology Policy, Baltimore, MD, USA
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