Creating a culture of research

The clinical impact of pain neuroscience continuing education on physical therapy outcomes for patients with low back and neck pain

Objectives

Research suggests that attendance by physical therapists at continuing education (CE) targeting the management of low back pain (LBP) and neck pain does not result in positive impacts on clinical outcomes. The aim of this study was to determine if therapists attending a self-paced 3-hour online Pain Neuroscience Education (PNE) program was associated with any observed changes to patient outcomes and also clinical practice.

Methods

Participants were 25 different physical therapists who treated 3,705 patients with low back pain (LBP) or neck pain before and after they had completed an online PNE CE course. Change in outcomes measures of pain and disability at discharge were compared for the patients treated before and after the therapist training. Clinical practice patterns of the therapists, including total treatment visits, duration of care, total units billed, average units billed per visit, percentage of ‘active’ billing units and percentage of ‘active and manual’ billing units, were also compared for the patient care episodes before and after the therapist training.

Results

There was no significant difference for change in pain scores at discharge for patients treated after therapist CE training compared to those treated before regardless of the condition (LBP or neck pain). However, patients with LBP who were treated after therapist CE training did report greater improvement in their disability scores. Also after CE training, for each episode of care, therapists tended to use less total visits, billed fewer units per visit, and billed a greater percentage of more ‘active’ and ‘active and manual’ billing units.

Discussion

Attending an online 3-hour CE course on PNE resulted in improved disability scores for patients with LBP, but not for those with neck pain. Changes in clinical behavior by the therapists included using less visits, billing fewer total units, and shifting to more active and manual therapy interventions. Further prospective studies with control groups should investigate the effect of therapist CE on patient outcomes and clinical practice.

An online survey to assess parents' preferences for learning about child health research

Aim

Ethical and logistical issues often exacerbate recruitment problems in child health studies. This study aims: (a) to provide new knowledge on how parents want to hear about child health research and (b) to inform the KidsCAN PERC iPCT initiative's re‐examination of recruitment and retention strategies for pediatric emergency department research studies.

Design

We employed a cross‐sectional, survey design.

Methods

An online survey was distributed to participants (i.e., parents) through partner organizations' advisory group mailing lists. Frequencies and measures of central tendency guided data analysis.

Results

Parents are interested in hearing about child health research opportunities, particularly during general practitioner, pediatrician or walk‐in clinic visits. Most parents wanted updates on the research team, progress and results and support to participate, such as reimbursement of travel and childcare costs. Results can inform research teams in the planning of communications to effectively share research opportunities, progress and results with parents.

Acceptability of a German multicentre healthcare research study: a survey of research personnels' attitudes, experiences and work load

OBJECTIVES

The DACAPO study as a multicentre nationwide observational healthcare research study investigates the influence of quality of care on the quality of life in patients with acute respiratory distress syndrome. The aim of this study was to investigate the acceptability to the participating research personnels by assessing attitudes, experiences and workload associated with the conduct of the DACAPO study.

DESIGN, SETTING AND PARTICIPANTS

A prospective anonymous online survey was sent via email account to 169 participants in 65 study centres. The questionnaire included six different domains: (1) training for performing the study; (2) obtaining informed consent; (3) data collection; (4) data entry using the online documentation system; (5) opinion towards the study and (6) personal data. Descriptive data analysis was carried out.

RESULTS

A total of 78 participants took part (46%) in the survey, 75 questionnaires (44%) could be evaluated. 51% were senior medical specialists. 95% considered the time frame of the training as appropriate and the presentation was rated by 93% as good or very good. Time effort for obtaining consent, data collection and entry was considered by 41% as a burden. Support from the coordinating study centre was rated as good or very good by more than 90% of respondents. While the DACAPO study was seen as scientifically relevant by 81%, only 45% considered the study results valuable for improving patient care significantly.

CONCLUSION

Collecting feedback on the acceptability of a large multicentre healthcare research study provided important insights. Recruitment and data acquisition was mainly performed by physicians and often regarded as additional time burden in clinical practice. Reducing the amount of data collection and simplifying data entry could facilitate the conduct of healthcare research studies and could improve motivation of researchers in intensive care medicine.

TRIAL REGISTRATION NUMBER

NCT02637011; Pre-results.

The Glomerular Disease Study and Trial Consortium: A Grassroots Initiative to Foster Collaboration and Innovation

Glomerular kidney disorders account for a significant proportion of chronic kidney disease and end-stage renal disease worldwide. Nevertheless, major obstacles make breakthrough progress in diagnosis and cure an ongoing challenge. Here we report the creation of a "grassroots" initiative that aims to provide new opportunities for nephrologists, pathologists, basic and clinical scientists, patients, and industry partners to collaborate in the field of glomerular kidney disease. Members of the medical community, including trainees, nephrologists, and nephropathologists, can participate in the open-access, Web-based, multidisciplinary clinical video case conferences, which provide "peer-to-peer" exchange of clinical and pathological expertise combined with a formal didactic curriculum. Participants can also join other aspects of the broader initiative. These include the participation in a multisite research study to facilitate enrollment of patients into a longitudinal clinical data and biorepository for glomerular kidney disorders. Items included in this prospective registry include the following: an ontology-based patient medical history, which is regularly updated; interval collection and storage of blood and urine samples; DNA collection; and a contact registry for patients who wish to participate in clinical trials. Participating sites and external scientists can leverage access to the database to pursue genetic, biomarker, epidemiological, and observational clinical effectiveness studies. Patients can independently sign up for a supplementary contact registry to participate in clinical trials if eligible. The broad spectrum of activities within this initiative will foster closer collaboration among trainees, practicing nephrologists, pathologists, and researchers, and may help to overcome some of the barriers to progress in the field of glomerular kidney disease.

Collaborative partnership and the social value of clinical research: a qualitative secondary analysis

BACKGROUND

Protecting human subjects from being exploited is one of the main ethical challenges for clinical research. However, there is also a responsibility to protect and respect the communities who are hosting the research. Recently, attention has focused on the most efficient way of carrying out clinical research, so that it benefits society by providing valuable research while simultaneously protecting and respecting the human subjects and the communities where the research is conducted. Collaboration between partners plays an important role and that is why we carried out a study to describe how collaborative partnership and social value are emerging in clinical research.

METHODS

A supra-analysis design for qualitative descriptive secondary analysis was employed to consider a novel research question that pertained to nurse leaders' perceptions of ethical recruitment in clinical research and the ethics-related aspects of clinical research from the perspective of administrative staff. The data consisted of two separate pre-existing datasets, comprising 451 pages from 41 interviews, and we considered the research question by using deductive-inductive content analysis with NVivo software. A deductive analysis matrix was generated on the basis of two requirements, namely collaborative partnership and social value, as presented in An Ethical Framework for Biomedical Research by Emanuel et al.

RESULTS

The findings showed that collaborative partnership was a cornerstone for ethical clinical research and ways to foster inter-partner collaboration were indicated, such as supporting mutual respect and equality, shared goals and clearly defined roles and responsibilities. In addition, the social value of clinical research was an important precondition for ethical clinical research and its realisation required the research partners to demonstrate collaboration and shared responsibility during the research process. However, concerns emerged that the multidimensional meaning of clinical research for society was not fully recognised. Achieving greater social value for clinical research required greater transparency, setting research priorities, shared responsibility for the dissemination and use of the findings and stronger community awareness of the ethics-related aspects of clinical research.

CONCLUSIONS

Collaborative partnership and social values are essential for protecting the human subjects and communities involved in clinical research.

Raising Public Awareness of Clinical Trials: Development of Messages for a National Health Communication Campaign

Clinical trials are essential for developing new and effective treatments and improving patient quality of life; however, many trials cannot answer their primary research questions because they fall short of their recruitment goals. This article reports the results of formative research conducted in two populations, the public and primary care physicians, to identify messages that may raise awareness and increase interest in clinical trials and be used in a national communication campaign. Results suggested that participants were primarily motivated to participate in clinical trials out of a self-interest to help themselves first. Messages illustrated that current treatments were tested via clinical trials, helped normalize trials as routine practices, and reduced concerns over trying something new first. Participants wanted messages that portray trials as state-of-the-art choices that offer some hope, show people like themselves, and are described in a clear, concise manner with actionable steps for them to take. The study revealed some differences in message salience, with healthy audiences exhibiting lower levels of interest. Our results suggest that targeted messages are needed, and that communication with primary health-care providers is an important and necessary component in raising patient awareness of the importance of clinical trials.

Engineering practice variation through provider agreement: a cluster-randomized feasibility trial

Purpose

Minimal-risk randomized trials that can be embedded in practice could facilitate learning health-care systems. A cluster-randomized design was proposed to compare treatment strategies by assigning clusters (eg, providers) to “favor” a particular drug, with providers retaining autonomy for specific patients. Patient informed consent might be waived, broadening inclusion. However, it is not known if providers will adhere to the assignment or whether institutional review boards will waive consent. We evaluated the feasibility of this trial design.

Subjects and methods

Agreeable providers were randomized to “favor” either hydrochlorothiazide or chlorthalidone when starting patients on thiazide-type therapy for hypertension. The assignment applied when the provider had already decided to start a thiazide, and providers could deviate from the strategy as needed. Prescriptions were aggregated to produce a provider strategy-adherence rate.

Results

All four institutional review boards waived documentation of patient consent. Providers (n=18) followed their assigned strategy for most of their new thiazide prescriptions (n=138 patients). In the “favor hydrochlorothiazide” group, there was 99% adherence to that strategy. In the “favor chlorthalidone” group, chlorthalidone comprised 77% of new thiazide starts, up from 1% in the pre-study period. When the assigned strategy was followed, dosing in the recommended range was 48% for hydrochlorothiazide (25–50 mg/day) and 100% for chlorthalidone (12.5–25.0 mg/day). Providers were motivated to participate by a desire to contribute to a comparative effectiveness study. A study promotional mug, provider information letter, and interactions with the site investigator were identified as most helpful in reminding providers of their study drug strategy.

Conclusion

Providers prescribed according to an assigned drug-choice strategy most of the time for the purpose of a comparative effectiveness study. This simple design could facilitate research participation and behavior change in non-research clinicians. Waiver of patient consent can broaden the representation of patients, providers, and settings.

'I heard about this study on the radio': using community radio to strengthen Good Participatory Practice in HIV prevention trials

Background

During the Microbicides Development Program (MDP) 301, a clinical trial of a candidate microbicide amongst women in Johannesburg, South Africa, we used community radio to promote awareness of the trial, to inform community members about specific medical research procedures and terminologies, and to stimulate dialogue between researchers and local citizens.

Methods

We used mixed methods to undertake a retrospective analysis of the social responses to the radio shows, focusing specifically on recruitment and participation in the MDP301 trial. We collected quantitative data that describes the themes and listener responses, the costs per broadcast, and the impact of the radio broadcasts on trial recruitment. Qualitative data on local reactions to the shows was gleaned from in-depth interviews with trial participants.

Results

Over a seven-year period, 205 individual broadcasts were made on two separate community radio stations. Show themes were either specifically related to medical research issues (36%), or focused on general health issues (46%), and sexual and reproductive health, including HIV prevention (18%). 403 listeners made telephone calls to the radio station, and 12% of women enrolled as participants in MDP301 (n = 9, 385) reported that they had first heard about the trial from the radio. Qualitative interviews (n = 401) with female MDP301 participants highlighted the effects of the radio shows in making women aware of the trial, impressing them with the importance of health screening and knowledge, legitimizing trial participation, and stimulating dialogue between trial participants and their male partners.

Conclusions

Community radio is a potent tool for raising awareness and local knowledge about medical research and, in addition to other methodologies, can be used to promote recruitment into clinical trials. We suggest that future HIV prevention trials consider an investment in community radio beyond recruitment advertisements that incorporates this into the broader community engagement plan as a key element of Good Participatory Practice in clinical trial settings.

Promoting Factors and Barriers to Participation in Early Phase Clinical Trials: Patients Perspectives

BACKGROUND

Inclusion of minorities in clinical research is an essential step to develop novel cancer treatments, improve health care overall, understand potential differences in pharmacogenomics and address minorities' disproportionate cancer burden. However, Latinos and other minority groups continue to be critically underrepresented, particularly in early-phase clinical trials (EPCTs). The objective of the present study was to explore barriers and promoting factors influencing patients' decisions to enroll or not in early phase clinical trials (EPCTs) and identify areas for intervention to increase minority enrollment into clinical research.

METHODS

An interviewer-administered survey was conducted with 100 cancer patients in the predominantly Latino region of South Texas. Exploratory factor analysis was conducted to identify underlying dimensions, and multiple logistic regression assessed significant factors that promote or deter patients enrollment to EPCTs. In addition, a separate subgroup mean analysis assessed differences by enrollment status and race/ethnicity.

RESULTS

For one standard deviation increase in the importance given to the possibility of symptoms improvement, the predicted odds of refusing enrollment were 3.20 times greater (OR=3.20, 95% CI=1.06-9.71, p 0.040). Regarding barriers, among patients who considered fear/uncertainty of the new treatment a deterrent to enrollment, one standard deviation increase in agreement with these barriers was associated with a 3.60 increase (OR=3.60, 95% CI=1.30-9.97h, p 0.014) in the odds of not being enrolled in an EPCT. In contrast, non-enrolled patients were less likely (OR=0.14, 95% CI=0.05-0.44, p 0.001) to consider fatalistic beliefs as an important barrier.

CONCLUSION

This study, one of the first to identify South Texas patients' barriers to enroll in EPCTs, highlights potential focal areas to increase participation of both minority and non-minority patients in clinical research. Culturally tailored interventions promoting patient-centered care and bilingual, culturally competent study teams could solve common barriers and enhance Latinos' likelihood of joining clinical trials. These interventions may simultaneously increase opportunities to involve patients and physicians in clinical trials, while ensuring the benefits of participation are equitably distributed to all patients.

Effect of medical oncologists' attitudes on accrual to clinical trials in a community setting

PURPOSE

Oncology clinical trials (OCTs) are crucial in evaluating new cancer treatments, but only 2% to 3% of US adult patients with cancer enter OCTs. This study assessed barriers to participation in clinical trials among oncologists in a large integrated health care delivery system with an active clinical trials program. Although many studies have identified major physician barriers to enrollment, few have examined how these barriers affect actual trial accrual.

METHODS

Using information from a mailed survey, we examined the effect of oncologists' attitudes, beliefs, experiences, sociodemographic factors, and practice characteristics on clinical trial accrual in the 2 years following the survey. We identified relationships between these variables and subsequent clinical trial accrual using correlations and mixed effects models.

RESULTS

A construct combining questions that assessed oncologist attitudes, beliefs, and experiences substantially influenced OCT enrollment (r = .51; P < .0001). This construct included awareness of open clinical trials and specific eligible patients, as well as the practice of initiating a discussion about OCTs with most eligible patients. This broad concept of awareness had the greatest correlation with enrollment and mediated the effect on enrollment of other values and beliefs, such as welcoming a patient's initiation of a trial discussion and valuing the support of research nurses and coordinators.

CONCLUSION

Even in a health care setting with an active clinical trials program, substantial research personnel, infrastructure support, and widespread access to trials among oncologists and patients, oncologists' participation remains quite variable. Oncologist values, beliefs, and awareness of clinical trials play an important role in OCT accrual.

Public awareness of clinical trials: A qualitative pilot study in Pune

Context:

Medical expertise combined with availability of patients with varied diseases have resulted in rapid increase in number of clinical trials (CTs) recruiting millions of patients in India. Yet, few researchers have tried to understand if the public in India is aware of CTs.

Aims:

To explore the awareness, perceptions of and attitude towards participating in CTs among general public in Pune.

Materials and Methods:

Focus group discussions (FGDs) and interviews were conducted by contacting people in the community of various age groups and socio economic status with 7 Trial participants (TPs) and 17 Non Trial Participants (NTPs). The survey tool consisted of open-ended questions that assessed the awareness and attitudes of the individuals regarding the CTs. Interview were recorded on paper and translated from (Marathi) local language to English for analysis. Qualitative analysis was used to report the findings.

Results:

Most participants could associate CTs with medicine or development of new medicine; however they did not have a good understanding of the manner and safeguards with which CTs are conducted. Participants were not aware about different types of CTs and phases of the CTs. CTs were felt to be of benefit to the community and advancement of science. However, due to fear of adverse effects, 80% of the respondents were not ready to participate in the CTs.

Conclusions:

The Indian Pharmaceutical company is the world's 3^rd largest by volume as per Dr. Shivathanu Pillai's report 17th March 2010, in spite of that it has been noticed that the awareness about CTs is very low; therefore there is a need to create awareness about CTs which helps the participants to participate in CTs based on their own decision. These FGD findings require validation in a larger sample.

Commonly performed procedures in clinical research: a benchmark for payment

Slow or insufficient enrollment in clinical research and a high demand for research participants raises questions about the need for and use of incentives to participate, including payment. Much of the available literature on payment to research participants focuses on ethical concerns, and rarely addresses guidelines, benchmarks, or formulas to assist investigators to assign or evaluate appropriate payment for individuals who take part in clinical research trials and procedures. Using four years of data collected about the inconvenience units assigned by intramural investigators to selected clinical research procedures conducted at the National Institutes of Health (NIH) Clinical Center, this study provides payment benchmarks for commonly performed procedures. Results were obtained from data collected on 36,273 incidents of payment made for procedures to research participants from August 2004 to August 2008. Analysis of the inconvenience units value assigned to specific procedures suggests that despite a wide distribution and frequent outliers, a convergence in practice around the center of distribution for most procedures does exist. As one of the first published studies reporting data reflecting payment amount for specific clinical research procedures, these data can guide investigators and institutional review boards as they establish and review an appropriate amount of payment to offer research participants. Our data may be useful in promoting payment standards for procedures, thereby complementing proposals or guidelines that advise payment calculations according to time and procedures.

A population-based assessment of specialty physician involvement in cancer clinical trials

BACKGROUND

Clinical trials are critical for evaluating new cancer therapies, but few adult patients participate in them. Physicians have an important role in facilitating patient participation in clinical trials. We examined the characteristics of specialty physicians who participate in clinical trials by enrolling or referring patients, the types of trials in which they participate, and factors associated with physicians who report greater involvement in clinical trials.

METHODS

We analyzed data from the Cancer Care Outcomes Research and Surveillance Consortium. The study included 1533 specialty physicians who cared for colorectal and lung cancer patients (496 medical oncologists, 228 radiation oncologists, and 809 surgeons) and completed a survey conducted during 2005-2006 (response rate = 61.0%). Descriptive statistics were used to characterize physicians' personal and practice characteristics, and regression models were used to examine associations between these characteristics and physician participation in clinical trials. All statistical tests were two-sided.

RESULTS

A total of 87.8% of medical oncologists, 66.1% of radiation oncologists, and 35.0% of surgeons reported referring or enrolling one or more patients in clinical trials during the previous 12 months. The mean number of patients referred or enrolled by these physicians was 17.2 (95% confidence interval [CI] = 15.5 to 18.9) for medical oncologists, 9.5 (95% CI = 7.7 to 11.3) for radiation oncologists, and 12.2 (95% CI = 9.8 to 14.6) for surgeons (P < .001). Specialty type, involvement in teaching, and affiliation with a Community Clinical Oncology Program (CCOP) and/or a National Cancer Institute-designated cancer center were associated with physician trial participation and enrolling more patients (all Ps < .05). Two-thirds of physicians with a CCOP or National Cancer Institute-designated cancer center affiliation reported participating in trials.

CONCLUSIONS

Features of specialty physicians' practice environments are associated with their trial participation, but many physicians at CCOPs and cancer centers do not participate.

Research ethics II: Mentoring, collaboration, peer review, and data management and ownership

PURPOSE

In this series of articles--Research Ethics I, Research Ethics II, and Research Ethics III--the authors provide a comprehensive review of the 9 core domains for the responsible conduct of research (RCR) as articulated by the Office of Research Integrity. In Research Ethics II, the authors review the RCR domains of mentoring, collaboration, peer review, and data management and ownership.

METHOD

They relied on authoritative documents, both historical and contemporary, insightful commentary, and empirical research in order to identify current issues and controversies of potential interest to both faculty and students.

CONCLUSIONS

The authors close by urging readers to stay abreast of the manifold ethics issues facing today's community of scientists, policymakers, and research institutions, and to adhere to best practices as they evolve.

Responsible conduct of research in communication sciences and disorders: faculty and student perceptions

PURPOSE

Two Web-based surveys (Surveys I and II) were used to assess perceptions of faculty and students in Communication Sciences and Disorders (CSD) regarding the responsible conduct of research (RCR).

METHOD

Survey questions addressed 9 RCR domains thought important to the responsible conduct of research: (a) human subjects protections; (b) research involving animals; (c) publication practices and responsible authorship; (d) mentor/trainee responsibilities; (e) collaborative science; (f) peer review; (g) data acquisition, management, sharing, and ownership; (h) conflicts of interest; and (i) research misconduct. Respondents rated each of 37 topics for importance and for sufficiency of instructional coverage.

RESULTS

Respondents to Survey I were 137 faculty members from 68 (26%) of the 261 graduate programs in CSD. By comparison, 237 students from 39 (15%) programs responded to Survey II. Data about the importance and sufficiency of coverage of each of the 37 items were transformed into z scores to reveal relative ratings among the 37 topics. Data presentations were grouped for topics in each of the 9 RCR domains. Ratings indicated the relatively high importance assigned among the 37 topics by CSD faculty and students. Sufficiency of coverage of those same topics received lower ratings.

CONCLUSIONS

The results of these surveys support the notion that students in CSD perceive that they are receiving information about RCR. The data pertaining to sufficiency of coverage provide a basis for improving instruction in this important aspect of research education.

Cardiology clinical trial participation in community-based healthcare systems: obstacles and opportunities

BACKGROUND

The objective of our study was to examine cardiologists' and organizational leaders' interest in clinical trial participation and perceived barriers and facilitators to participation within ten diverse non-profit healthcare delivery systems. Trials play a pivotal role in advancing knowledge about the safety and efficacy of cardiovascular interventions and tests. Although cardiovascular trials successfully enroll patients, recruitment challenges persist. Community-based health systems could be an important source of participants and investigators, but little is known about community cardiologists' experiences with trials.

METHODS

We interviewed 25 cardiology and administrative leaders and mailed questionnaires to all 280 cardiologists at 10 U.S. healthcare organizations.

RESULTS

The survey received a 73% response rate. While 60% of respondents had not participated in any trials in the past year, nearly 75% wanted greater participation. Cardiologists reported positive attitudes toward trial participation; more than half agreed that trials were their first choice of therapy for patients, if available. Almost all leaders described their organizations as valuing research but not necessarily trials. Major barriers to participation were lack of physician time and insufficient skilled research nurses.

CONCLUSIONS

Cardiologists have considerable interest in trial participation. Major obstacles to increased participation are lack of time and effective infrastructure to support trials. These results suggest that community-based health systems are a rich source for cardiovascular research but additional funding and infrastructure are needed to leverage this resource.