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Wilson MG, Palmer E, Asselbergs FW, Harris SK. Integrated rapid-cycle comparative effectiveness trials using flexible point of care randomisation in electronic health record systems. J Biomed Inform 2023; 137:104273. [PMID: 36535604 DOI: 10.1016/j.jbi.2022.104273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 10/13/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Whilst the Randomised Controlled Trial remains the gold standard for deriving robust causal estimates of treatment efficacy, too often a traditional design proves prohibitively expensive or cumbersome when it comes to assessing questions regarding the comparative effectiveness of routinely used treatments. As a result, patients experience variation in practice as clinicians lack the evidence needed to personalise treatments effectively. This variation may be classified as unwarranted, where existing evidence is ignored, or legitimate where in the absence of evidence, clinicians rely on experience, expert opinion, and inferred principles from basic science to make decisions. We argue that within the right ethical and technological framework, legitimate variation can be transformed into a mechanism for evidence generation and learning. Learning Health Systems which harness existing variation in practice, represent a novel approach for generating evidence from everyday clinical practice. The development of these systems has gained traction due to the increased availability of modern Electronic Health Record Systems. However, despite their promise, overcoming hurdles to successfully integrating clinical trials within Learning Health Systems has proven challenging. This article describes the origins of integrated clinical trials and explores two main barriers to their further implementation - how best to obtain informed consent from patients to participate in routine comparative effectiveness research, and how to automate and integrate randomisation into a clinical workflow. Having described these barriers, we present a potential solution in the form of a research pipeline using a novel form of flexible point-of-care randomisation to allow clinicians and patients to participate in studies where there is clinical equipoise.
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Affiliation(s)
- Matthew G Wilson
- Institute of Health Informatics, Faculty of Population Health Sciences, University College London, UK.
| | - Edward Palmer
- Bloomsbury Institute of Intensive Care Medicine, University College London, UK; Whittington Hospital NHS Trust, UK
| | - Folkert W Asselbergs
- Institute of Cardiovascular Science and Institute of Health Informatics, Faculty of Population Health Sciences, University College London, UK; Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Steve K Harris
- Institute of Health Informatics, Faculty of Population Health Sciences, University College London, UK; Critical Care Department, University College London Hospital, UK
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Wilson MG, Asselbergs FW, Miguel R, Brealey D, Harris SK. Embedded point of care randomisation for evaluating comparative effectiveness questions: PROSPECTOR-critical care feasibility study protocol. BMJ Open 2022; 12:e059995. [PMID: 36123103 PMCID: PMC9486229 DOI: 10.1136/bmjopen-2021-059995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Many routinely administered treatments lack evidence as to their effectiveness. When treatments lack evidence, patients receive varying care based on the preferences of clinicians. Standard randomised controlled trials are unsuited to comparisons of different routine treatment strategies, and there remains little economic incentive for change.Integrating clinical trial infrastructure into electronic health record systems offers the potential for routine treatment comparisons at scale, through reduced trial costs. To date, embedded trials have automated data collection, participant identification and eligibility screening, but randomisation and consent remain manual and therefore costly tasks.This study will investigate the feasibility of using computer prompts to allow flexible randomisation at the point of clinical decision making. It will compare the effectiveness of two prompt designs through the lens of a candidate research question-comparing liberal or restrictive magnesium supplementation practices for critical care patients. It will also explore the acceptability of two consent models for conducting comparative effectiveness research. METHODS AND ANALYSIS We will conduct a single centre, mixed-methods feasibility study, aiming to recruit 50 patients undergoing elective surgery requiring postoperative critical care admission. Participants will be randomised to either 'Nudge' or 'Preference' designs of electronic point-of-care randomisation prompt, and liberal or restrictive magnesium supplementation.We will judge feasibility through a combination of study outcomes. The primary outcome will be the proportion of prompts displayed resulting in successful randomisation events (compliance with the allocated magnesium strategy). Secondary outcomes will evaluate the acceptability of both prompt designs to clinicians and ascertain the acceptability of pre-emptive and opt-out consent models to patients. ETHICS AND DISSEMINATION This study was approved by Riverside Research Ethics Committee (Ref: 21/LO/0785) and will be published on completion. TRIAL REGISTRATION NUMBER NCT05149820.
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Affiliation(s)
- Matthew G Wilson
- Institute of Health Informatics, University College London, London, UK
| | - Folkert W Asselbergs
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Ruben Miguel
- Clinical Research Informatics Unit, Institute of Health Informatics, University College London, London, UK
| | - David Brealey
- Bloomsbury Institute for Intensive Care Medicine, University College London, London, UK
- Critical Care Department, University College London Hospitals NHS Foundation Trust, London, UK
| | - Steve K Harris
- Institute of Health Informatics, University College London, London, UK
- Critical Care Department, University College London Hospitals NHS Foundation Trust, London, UK
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Casey JD, Beskow LM, Brown J, Brown SM, Gayat É, Ng Gong M, Harhay MO, Jaber S, Jentzer JC, Laterre PF, Marshall JC, Matthay MA, Rice TW, Rosenberg Y, Turnbull AE, Ware LB, Self WH, Mebazaa A, Collins SP. Use of pragmatic and explanatory trial designs in acute care research: lessons from COVID-19. THE LANCET. RESPIRATORY MEDICINE 2022; 10:700-714. [PMID: 35709825 PMCID: PMC9191864 DOI: 10.1016/s2213-2600(22)00044-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/21/2021] [Accepted: 01/20/2022] [Indexed: 12/15/2022]
Abstract
Unique challenges arise when conducting trials to evaluate therapies already in common clinical use, including difficulty enrolling patients owing to widespread open-label use of trial therapies and the need for large sample sizes to detect small but clinically meaningful treatment effects. Despite numerous successes in trials evaluating novel interventions such as vaccines, traditional explanatory trials have struggled to provide definitive answers to time-sensitive questions for acutely ill patients with COVID-19. Pragmatic trials, which can increase efficiency by allowing some or all trial procedures to be embedded into clinical care, are increasingly proposed as a means to evaluate therapies that are in common clinical use. In this Personal View, we use two concurrently conducted COVID-19 trials of hydroxychloroquine (the US ORCHID trial and the UK RECOVERY trial) to contrast the effects of explanatory and pragmatic trial designs on trial conduct, trial results, and the care of patients managed outside of clinical trials. In view of the potential advantages and disadvantages of explanatory and pragmatic trial designs, we make recommendations for their optimal use in the evaluation of therapies in the acute care setting.
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Affiliation(s)
- Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Laura M Beskow
- Vanderbilt Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeremy Brown
- Office of Emergency Care Research, National Institute of Neurological Disorders and Stroke, Division of Clinical Research, National Institutes of Health, Bethesda, MD, USA
| | - Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and University of Utah, Salt Lake City, UT, USA
| | - Étienne Gayat
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; INSERM UMR-S 942, MASCOT, Université Paris Cité, Paris, France
| | - Michelle Ng Gong
- Division of Critical Care Medicine and Division of Pulmonary Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Michael O Harhay
- Palliative and Advanced Illness Research (PAIR) Center Clinical Trials Methods and Outcomes Lab, and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Samir Jaber
- Saint Eloi Intensive Care Unit, Montpellier University Hospital, and PhyMedExp, INSERM, CNRS, Université de Montpellier, Montpellier, France
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pierre-François Laterre
- Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, Brussels, Belgium
| | - John C Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; INSERM UMR-S 942, MASCOT, Université Paris Cité, Paris, France
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education,and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Kass NE, Faden RR, Morain SR, Hallez K, Stametz RA, Milo AR, Clarke D. Streamlined versus traditional consent for low-risk comparative effectiveness trials: a randomized experimental study to measure patients' and public attitudes. J Comp Eff Res 2022; 11:329-346. [PMID: 35238218 DOI: 10.2217/cer-2021-0173] [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: 11/21/2022] Open
Abstract
Aim: Streamlining consent for low-risk comparative effectiveness research (CER) could facilitate research, while safeguarding patients' rights. Materials & methods: 2618 adults were randomized to one of seven consent approaches (six streamlined and one traditional) for a hypothetical, low-risk CER study. A survey measured understanding, voluntariness, and feelings of respect. Results: Participants in all arms had a high understanding of the trial and positive attitudes toward the consent interaction. Highest satisfaction was with a streamlined approach showing a video before the medical appointment. Participants in streamlined were more likely to mistakenly think a signature was required. Conclusion: Streamlined consent was no less acceptable than traditional, signed consent. Streamlined and traditional approaches achieved similar levels of understanding, voluntariness and a feeling that the doctor-patient interaction was respectful.
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Affiliation(s)
- Nancy E Kass
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD 21205, USA.,Johns Hopkins University, Baltimore, MD 21205, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Ruth R Faden
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD 21205, USA
| | - Stephanie R Morain
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD 21205, USA.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Kristina Hallez
- Center for Effective Global Action, University of California, Berkeley
| | - Rebecca A Stametz
- Steele Institute for Health Innovation, Geisinger, Danville, PA 17822, USA
| | - Amanda R Milo
- Steele Institute for Health Innovation, Geisinger, Danville, PA 17822, USA
| | - Deserae Clarke
- University of Arizona College of Medicine - Phoenix, Division of Clinical Data Analytics & Decision Support, Phoenix, AZ 85004, USA
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Monach PA, Branch-Elliman W. Reconsidering 'minimal risk' to expand the repertoire of trials with waiver of informed consent for research. BMJ Open 2021; 11:e048534. [PMID: 34521663 PMCID: PMC8442055 DOI: 10.1136/bmjopen-2020-048534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Progress in therapeutic research is slowed by the regulatory burden of clinical trials, which provide the best evidence for guiding treatment. There is a long delay from evidence generation to adoption, highlighting the need for designs that link evidence generation to implementation. OBJECTIVE To identify clinical trial designs that confer minimal risk above that inherent in clinical care, to obviate the need for cumbersome consenting processes to enrol patients in prospective clinical research studies. These designs extend the scope of the Learning Healthcare System, a framework for leveraging retrospective 'big data' to advance clinical research, to include data collected from prospective controlled trials. SUMMARY Pragmatic trials may use simplified eligibility criteria, unblinded interventions and objective outcome measures that can all be monitored through the electronic health records (EHR), to reduce costs and speed study conduct. Most pragmatic trials continue to suffer from substantial regulatory burden. Written consent to participate in research can be waived only if the research produces minimal risk above what is encountered in everyday life. However, the 'consent' processes for prescribing Federal Drug Administration-approved medications in clinical medicine are informal, even when they involve decisions of uncertain benefit and higher levels of risk. We propose that trial designs that mimic clinical decision-making in areas of uncertainty (clinical equipoise) and in which no data are generated outside of usual care (ideally by EHR embedding) confer minimal additional risk. Trial designs meeting this standard could, therefore, be conducted with minimal documentation of consent, even when interventions contain different risks. To align with risk encountered in clinical practice, allocation to treatment arms should change (adaptive randomisation) as data are collected and analysed. Embedding of informatics tools into the EHR has the additional benefit that, as adaptive randomisation progresses, evidence-generation transitions into implementation via decision-support tools-the ultimate realisation of the Learning Healthcare System.
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Affiliation(s)
- Paul A Monach
- Rheumatology Section, VA Boston Health Care System Jamaica Plain Campus, Boston, Massachusetts, USA
| | - Westyn Branch-Elliman
- Infectious Diseases Section, VA Boston Health Care System West Roxbury Campus, West Roxbury, Massachusetts, USA
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McLeish J, Alderdice F, Robberts H, Cole C, Dorling J, Gale C. Challenges of a simplified opt-out consent process in a neonatal randomised controlled trial: qualitative study of parents' and health professionals' views and experiences. Arch Dis Child Fetal Neonatal Ed 2021; 106:244-250. [PMID: 33139313 PMCID: PMC8070626 DOI: 10.1136/archdischild-2020-319545] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/07/2020] [Accepted: 09/10/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND More effective recruitment strategies like alternative approaches to consent are needed to facilitate adequately powered trials. Witholding Enteral feeds Around Transfusion was a multicentre, randomised, pilot trial that compared withholding and continuing feeds around transfusion. The primary clinical outcome was necrotising enterocolitis. The trial used simplified opt-out consent with concise parent information and no consent form. OBJECTIVE To explore the views and experiences of parents and health professionals on the acceptability and feasibility of opt-out consent in randomised comparative effectiveness trials. METHODS A qualitative, descriptive interview-based study nested within a randomised trial. Semistructured interview transcripts were analysed using inductive thematic analysis. SETTING Eleven neonatal units in England. PARTICIPANTS Eleven parents and ten health professionals with experience of simplified consent. RESULTS Five themes emerged: 'opt-out consent operationalised as verbal opt-in consent', 'opt-out consent normalises participation while preserving parental choice', 'opt-out consent as an ongoing process of informed choice', 'consent without a consent form' and 'choosing to opt out of a comparative effectiveness trial', with two subthemes: 'wanting "normal care"' and 'a belief that feeding is better'. CONCLUSION Introducing a novel form of consent proved challenging in practice. The principle of a simplified, opt-out approach to consent was generally considered feasible and acceptable by health professionals for a neonatal comparative effectiveness trial. The priority for parents was having the right to decide about trial participation, and they did not see opt-out consent as undermining this. Describing a study as 'opt-out' can help to normalise participation and emphasise that parents can withdraw consent.
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Affiliation(s)
- Jenny McLeish
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Oxford, Oxfordshire, UK
| | - Fiona Alderdice
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Oxford, Oxfordshire, UK
| | | | - Christina Cole
- Nuffield Department of Population Health, National Perinatal Epidemiology Unit, Oxford, Oxfordshire, UK
| | - Jon Dorling
- Division of Neonatal–Perinatal Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Chris Gale
- Academic Neonatal Medicine, School of Public Health, Faculty of Medicine, Imperial College London, London, UK
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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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Abstract
There is intense debate around the use of altered and waived consent for pragmatic trials. Those in favor argue that traditional consent compromises the internal and external validity of these trials. Those against, warn that the resultant loss of autonomy compromises respect for persons and could undermine trust in the research enterprise.This article examines whether international ethical guidelines and the policy frameworks in three countries-the United States, England, and Australia-permit altered and waived consent for minimal-risk pragmatic trials conducted outside the emergency setting. Provisions for both are clearly articulated in U.S. regulations, but many countries do not have equivalent frameworks. Investigators should not assume that all consent models permitted in the United States are legal in their jurisdictions, even if they are deemed ethically defensible.The authors summarize ethical and regulatory considerations and present a framework for investigators contemplating trials with altered or waived consent.
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Morain SR, Kass NE, Faden RR. Learning Is Not Enough: Earning Institutional Trustworthiness Through Knowledge Translation. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:31-34. [PMID: 29621442 DOI: 10.1080/15265161.2018.1431708] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
| | - Nancy E Kass
- b Johns Hopkins University and Johns Hopkins Bloomberg School of Public Health
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