A Brief Educational Intervention May Increase Public Acceptance of Emergency Research Without Consent

Public support for and concerns regarding pediatric dose optimization for seizures in emergency medical services: An exception from informed consent (EFIC) trial

BACKGROUND

Federal regulations allow exception from informed consent (EFIC) to study emergent conditions when obtaining prospective consent is not feasible. Little is known about public views on including children in EFIC studies. The Pediatric Dose Optimization for Seizures in EMS (PediDOSE) trial implements age-based, standardized midazolam dosing for pediatric seizures. The primary objective of this study was to determine public support for and concerns about the PediDOSE EFIC trial. The secondary objective was to assess how support for PediDOSE varied by demographics.

METHODS

We conducted a mixed-methods study in 20 U.S. communities. Participants reviewed information about PediDOSE before completing an online survey. Descriptive data were generated. Univariable and multivariable logistic regression analysis identified factors associated with support for PediDOSE. Reviewers identified themes from free-text response data regarding participant concerns.

RESULTS

Of 2450 respondents, 79% were parents/guardians, and 20% had a child with previous seizures. A total of 96% of respondents supported PediDOSE being conducted, and 70% approved of children being enrolled without prior consent. Non-Hispanic Black respondents were less likely than non-Hispanic White respondents to support PediDOSE with an adjusted odds ratio (aOR) of 0.57 (95% CI 0.42-0.75). Health care providers were more likely to support PediDOSE, with strongest support among prehospital emergency medicine clinicians (aOR 5.82, 95% CI 3.19-10.62). Age, gender, parental status, and level of education were not associated with support of PediDOSE. Common concerns about PediDOSE included adverse effects, legal and ethical concerns about enrolling without consent, and potential racial bias.

CONCLUSIONS

In communities where this study will occur, most respondents supported PediDOSE being conducted with EFIC and most approved of children being enrolled without prior consent. Support was lowest among non-Hispanic Black respondents and highest among health care providers. Further research is needed to determine optimal ways to address the concerns of specific racial and ethnic groups when conducting EFIC trials.

Ethical considerations in prehospital ambulance based research: qualitative interview study of expert informants

Background

Prehospital ambulance based research has unique ethical considerations due to urgency, time limitations and the locations involved. We sought to explore these issues through interviews with experts in this research field.

Methods

We undertook semi-structured interviews with expert informants, primarily based in the UK, seeking their views and experiences of ethics in ambulance based clinical research. Participants were questioned regarding their experiences of ambulance based research, their opinions on current regulations and guidelines, and views about their general ethical considerations. Participants were chosen because they were actively involved in, or in their expert capacity (e.g. law) expressed an interest in, ambulance based research.

Results

Fourteen participants were interviewed including principal investigators, researchers, ethicists and medical lawyers. Five major themes were identified: Capacity, Consent, Clinical Considerations, Consultation and Regulation. Questions regarding consent and capacity were foremost in the discussions as all participants highlighted these as areas for concern. The challenges and use of multiple consent models reflected the complexity of research in this environment. The clinical theme referred to the role of paramedics in research and how research involving ambulance services is increasingly informing improvements to patient care and outcomes and reducing the burden on hospital services. Most felt that, although current regulations were fit for purpose, more specific guidance on implementing these in the ambulance setting would be beneficial. This related closely to the theme of consultation, which examined the key role of ethics committees and other regulatory bodies, as well as public engagement.

Conclusions

By interviewing experts in research or ethics in this setting we were able to identify key concerns and highlight areas for future development such as improved guidance.

Strategies to improve recruitment to randomised trials

BACKGROUND

Recruiting participants to trials can be extremely difficult. Identifying strategies that improve trial recruitment would benefit both trialists and health research.

OBJECTIVES

To quantify the effects of strategies for improving recruitment of participants to randomised trials. A secondary objective is to assess the evidence for the effect of the research setting (e.g. primary care versus secondary care) on recruitment.

SEARCH METHODS

We searched the Cochrane Methodology Review Group Specialised Register (CMR) in the Cochrane Library (July 2012, searched 11 February 2015); MEDLINE and MEDLINE In Process (OVID) (1946 to 10 February 2015); Embase (OVID) (1996 to 2015 Week 06); Science Citation Index & Social Science Citation Index (ISI) (2009 to 11 February 2015) and ERIC (EBSCO) (2009 to 11 February 2015).

SELECTION CRITERIA

Randomised and quasi-randomised trials of methods to increase recruitment to randomised trials. This includes non-healthcare studies and studies recruiting to hypothetical trials. We excluded studies aiming to increase response rates to questionnaires or trial retention and those evaluating incentives and disincentives for clinicians to recruit participants.

DATA COLLECTION AND ANALYSIS

We extracted data on: the method evaluated; country in which the study was carried out; nature of the population; nature of the study setting; nature of the study to be recruited into; randomisation or quasi-randomisation method; and numbers and proportions in each intervention group. We used a risk difference to estimate the absolute improvement and the 95% confidence interval (CI) to describe the effect in individual trials. We assessed heterogeneity between trial results. We used GRADE to judge the certainty we had in the evidence coming from each comparison.

MAIN RESULTS

We identified 68 eligible trials (24 new to this update) with more than 74,000 participants. There were 63 studies involving interventions aimed directly at trial participants, while five evaluated interventions aimed at people recruiting participants. All studies were in health care.We found 72 comparisons, but just three are supported by high-certainty evidence according to GRADE.1. Open trials rather than blinded, placebo trials. The absolute improvement was 10% (95% CI 7% to 13%).2. Telephone reminders to people who do not respond to a postal invitation. The absolute improvement was 6% (95% CI 3% to 9%). This result applies to trials that have low underlying recruitment. We are less certain for trials that start out with moderately good recruitment (i.e. over 10%).3. Using a particular, bespoke, user-testing approach to develop participant information leaflets. This method involved spending a lot of time working with the target population for recruitment to decide on the content, format and appearance of the participant information leaflet. This made little or no difference to recruitment: absolute improvement was 1% (95% CI -1% to 3%).We had moderate-certainty evidence for eight other comparisons; our confidence was reduced for most of these because the results came from a single study. Three of the methods were changes to trial management, three were changes to how potential participants received information, one was aimed at recruiters, and the last was a test of financial incentives. All of these comparisons would benefit from other researchers replicating the evaluation. There were no evaluations in paediatric trials.We had much less confidence in the other 61 comparisons because the studies had design flaws, were single studies, had very uncertain results or were hypothetical (mock) trials rather than real ones.

AUTHORS' CONCLUSIONS

The literature on interventions to improve recruitment to trials has plenty of variety but little depth. Only 3 of 72 comparisons are supported by high-certainty evidence according to GRADE: having an open trial and using telephone reminders to non-responders to postal interventions both increase recruitment; a specialised way of developing participant information leaflets had little or no effect. The methodology research community should improve the evidence base by replicating evaluations of existing strategies, rather than developing and testing new ones.

A Novel Emergency Department-based Community Notification Method for Clinical Research Without Consent

OBJECTIVE

We used an emergency department (ED)-based method to provide targeted, individualized consultation; community notification; and public disclosure and collect data regarding willingness to participate in prospective resuscitation research requiring waiver of consent.

METHODS

We conducted a prospective survey of convenience cohort in an urban ED. We targeted the community of ED patients with pulmonary disease for individualized notification and public disclosure using a 1) large poster, 2) scripted oral presentation describing an emergency intubation clinical trial, and 3) video demonstration.

RESULTS

Approximately 10% of our annual ED census, 6,936 subjects, enrolled. Of that total, 29 were also subjects in a prospective coincident endotracheal resuscitation intubation study, which enrolled a total of 262 subjects. ED community notification was provided to 22 of the 29 (75.9%) subjects prior to the visit during which they were intubated (13 agreed to participate, six declined, and three undecided) and seven of the 29 subjects subsequent to enrollment in the intubation study (five agreed to participate and two undecided). Fourteen of the 29 patients who participated in both projects had undergone endotracheal intubation at least once prior to community notification: 10 agreed to participate in the study, two declined, and two were undecided.

CONCLUSIONS

Emergency department-based community notification and public disclosure is a viable way to provide information to a target population and collect data about the success of the notification. Feedback data collection is critical to an ethical understanding of the success of community notification for the institutional review board and investigators. Collection of feedback data should be required as a subject protection for exception from informed consent in emergency settings.

Exceptions to the rule of informed consent for research with an intervention

BACKGROUND

In specific situations it may be necessary to make an exception to the general rule of informed consent for scientific research with an intervention. Earlier reviews only described subsets of arguments for exceptions to waive consent.

METHODS

Here, we provide a more extensive literature review of possible exceptions to the rule of informed consent and the accompanying arguments based on literature from 1997 onwards, using both Pubmed and PsycINFO in our search strategy.

RESULTS

We identified three main categories of arguments for the acceptability of a consent waiver: data validity and quality, major practical problems, and distress or confusion of participants. Approval by a medical ethical review board always needs to be obtained. Further, we provide examples of specific conditions under which consent waiving might be allowed, such as additional privacy protection measures.

CONCLUSIONS

The reasons legitimized by the authors of the papers in this overview can be used by researchers to form their own opinion about requesting an exception to the rule of informed consent for their own study. Importantly, rules and guidelines applicable in their country, institute and research field should be followed. Moreover, researchers should also take the conditions under which they feel an exception is legitimized under consideration. After discussions with relevant stakeholders, a formal request should be sent to an IRB.

Variation of community consultation and public disclosure for a pediatric multi-centered "Exception from Informed Consent" trial

BACKGROUND

The US federal regulation "Exception from Informed Consent for Emergency Research," 21 Code of Federal Regulations 50.24, permits emergency research without informed consent under limited conditions. Additional safeguards to protect human subjects include requirements for community consultation and public disclosure prior to starting the research. Because the regulations are vague about these requirements, Institutional Review Boards determine the adequacy of these activities at a local level. Thus, there is potential for broad interpretation and practice variation.

AIM

To describe the variation of community consultation and public disclosure activities approved by Institutional Review Boards, and the effectiveness of this process for a multi-center, Exception from Informed Consent, pediatric status epilepticus clinical research trial.

METHODS

Community consultation and public disclosure activities were analyzed for each of the 15 participating sites. Surveys were conducted with participants enrolled in the status epilepticus trial to assess the effectiveness of public disclosure dissemination prior to study enrollment.

RESULTS

Every Institutional Review Board, among the 15 participating sites, had a varied interpretation of Exception from Informed Consent regulations for community consultation and public disclosure activities. Institutional Review Boards required various combinations of focus groups, interviews, surveys, and meetings for community consultation, and news releases, mailings, and public service announcements for public disclosure. At least 4335 patients received information about the study from these efforts. In all, 158 chose to be included in the "Opt Out" list. Of the 304 participants who were enrolled under Exception from Informed Consent, 12 (5%) had heard about the study through community consultation or public disclosure activities. The activities reaching the highest number of participants were surveys and focus groups associated with existing meetings. Public disclosure activities were more efficient and cost-effective if they were part of an in-hospital resource for patients and families.

CONCLUSION

There is substantial variation in Institutional Review Boards' interpretations of the federal regulations for community consultation and public disclosure. One of the goals of community consultation and public disclosure efforts for emergency research is to provide community members an opportunity to opt out of Exception from Informed Consent research; however, rarely do patients or their legally authorized representatives report having learned about a study prior to enrollment.

Waiver of informed consent in pediatric resuscitation research: a systematic review

BACKGROUND

In critical care and emergency medicine research, obtaining consent can be problematic when patients present with life-threatening conditions. This issue is further complicated in children, as even while coherent, they are often incapable of making decisions regarding their own care. To enable the ethical conduct of research in such situations, the Food and Drug Administration (FDA) of the United States has set recommendations for the conduct of research employing a waiver of consent. These regulations have been termed "exception from informed consent," or EFIC. As this is an evolving concept with limited pediatric experience, the authors conducted a review to examine the conduct of emergency research in the absence of prospectively obtained informed consent. Our review focused both on opinions and on the ability to conduct research without informed consent in life-threatening situations.

METHODS

A systematic review of the literature was undertaken in accordance with the PRISMA guidelines. Medline, CINAHL, and EMBASE databases were searched on January 9, 2013. Eligibility criteria included: 1) examined a method of conducting research in a life-threatening situation, 2) involved a real or theoretical clinical situation, 3) involved patients less than 18 years of age or a substitute decision-maker, and 4) reported at least one quantifiable outcome. The findings were synthesized qualitatively with the pertinent results summarized and discussed.

RESULTS

Eleven articles matched the eligibility criteria. Six focused on community consultation and public disclosure, three focused on the feasibility of employing a waiver of consent, and two examined attitudes toward emergency research. Of the studies focusing on community consultation, four defined the community as previous or current patients and health care providers and administrators in the study's home institution; the other two defined the community as the general population. Although there was heterogeneity in study designs, settings, and outcome measures, overall 68% (3,219 of 4,767) of subjects surveyed supported the use of EFIC under select circumstances (individual study range = 50% to 92%). Caregiver support increased among those in whom the situation was a more possible reality (e.g., critical care unit patients) and varied by the scenario and method of presentation (e.g., bulleted handout vs. preferred). Several studies revealed that patient accrual and time to intervention are impeded when prospective informed consent is required. Finally, deferred consent, although endorsed and used outside of the United States, continues to raise important ethical questions, particularly related to the need and timing of disclosure.

CONCLUSIONS

Limited data exist evaluating ethical issues in pediatric acute care resuscitation research. This review highlighted the fact that every proposal is unique and the method of obtaining consent (or waiver) requires careful consideration by local ethics committees. Particular attention must be paid to use of the population selected for community consultation. Several studies highlighted the need to consider the use of alternatives to prospective informed consent to enable the conduct of research in emergency departments (EDs) in life-threatening situations. Future research should evaluate children's opinions on this topic.

Ischemic stroke survivors' opinion regarding research utilizing exception from informed consent

INTRODUCTION

'Exception from informed consent for research' (EFIC) is a rigorous procedure regulated by the FDA that requires community assent but allows enrollment without patient or family consent. Recently, several acute stroke trials have explored the use of EFIC to improve enrollment. We obtained ischemic stroke survivors' opinions regarding hypothetical enrollment into a clinical trial at the time of their stroke without personal or proxy consent.

METHODS

During 2005, 460 ischemic stroke patients (or their proxy) who met case criteria were prospectively interviewed and followed. After 2 years, patients were asked to think back to the time of their stroke and indicate whether they would have wished to be enrolled in an acute stroke research study before individual or proxy consent could be obtained, understanding that consent would be sought as soon as possible thereafter, and they rated how agreeable they would have been to acute stroke research with different levels of invasiveness. Predictors of a positive opinion regarding the hypothetical research were analyzed using logistic regression. Variables included in the model were age, race, sex, education, initial NIHSS, modified Rankin Scale prior to stroke and 30 days after stroke, and proxy versus patient responder.

RESULTS

At 2 years after stroke, after excluding patient deaths, missing data or refusals, there were 194 patient/proxy responses included in this analysis. Overall, 72-79% of responses were favorable for chart review or blood draw without consent. The proportions answering agreeably to questions about medications or invasive strategies were smaller (62.9 and 59.8%). Older subjects were less likely to offer an agreeable response regarding use of medications [OR 0.97 per year (95% CI 0.94-0.99)] and invasive procedures [OR 0.97 per year (95% CI 0.94-0.99)]. Nonblacks tended to be more agreeable than blacks to invasive procedures. Men had twice the odds of being agreeable to blood draws than women.

CONCLUSIONS

We found that the majority of interviewed ischemic stroke patients were agreeable to being enrolled in acute stroke research with exception from informed consent, although the rates of agreement were lower than we expected among a cohort of patients who had already agreed to research. Older subjects, black race, and women were less likely to agree to blood draws or treatment strategies.

Public opinion of a stroke clinical trial using exception from informed consent

BACKGROUND

Acute stroke is a leading cause of morbidity and mortality. Clinical trials in stroke are challenging because victims often do not have the capacity to provide informed consent, excluding those patients most likely to benefit from the research.

AIM

We evaluated patient willingness to participate in a hypothetical acute stroke trial using an exception from informed consent.

METHODS

Consecutive patients presenting to four emergency departments (EDs) underwent structured interviews regarding a hypothetical stroke trial using an exception from informed consent.

RESULTS

Of 461 (72% of eligible) participants, 55% (95% CI, 50%-59%) were willing to be enrolled in the hypothetical study without giving informed consent. After multivariable analysis, independent predictors of willingness to enroll included Catholic religion (OR 1.57, 95% CI 1.17-2.10) and belief that current therapy offers a >50% chance of full recovery (OR 1.29, 95% CI 1.05-1.57). There was no difference between the proportion willing to enroll in a cardiac arrest study vs. a stroke study (55% vs. 55%, p = 0.83)

CONCLUSIONS

Fifty-five percent of ED patients would be willing to be enrolled in a stroke trial using exception from informed consent.