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Napit IB, Shrestha D, Choudhury S, Gkini E, Ilozumba O, Gill P, Bishop J, Neupane K, Adhikari A, Sartori J, Watson SI, Lilford R. A randomised Trial of Autologous Blood products, leukocyte and platelet-rich fibrin (L-PRF), to promote ulcer healing in LEprosy: The TABLE trial. PLoS Negl Trop Dis 2024; 18:e0012088. [PMID: 38696527 PMCID: PMC11093377 DOI: 10.1371/journal.pntd.0012088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 05/14/2024] [Accepted: 03/20/2024] [Indexed: 05/04/2024] Open
Abstract
INTRODUCTION Autologous blood products like Platelet Rich Plasma (PRP) and Leukocyte and Platelets Rich Fibrin (L-PRF) have been used for many years across many types of skin ulcers. However, the effectiveness of autologous blood products on wound healing is not well established. METHODS We evaluated the 'second generation' autologous product- Leukocyte and Platelet- Rich Fibrin (L-PRF). Our trial was undertaken on patients suffering from neuropathic leprosy ulcers at the Anandaban hospital which serves the entire country of Nepal. We conducted a 1:1 (n = 130) individually randomised trial of L-PRF (intervention) vs. normal saline dressing (control) to compare rate of healing and time to complete healing. Rate of healing was estimated using blind assessments of ulcer areas based on three different measurement methods. Time to complete healing was measured by the local unblinded clinicians and by blind assessment of ulcer images. RESULTS The point estimates for both outcomes were favourable to L-PRF but the effect sizes were small. Unadjusted mean differences (intervention vs control) in mean daily healing rates (cm2) were respectively 0.012 (95% confidence interval 0.001 to 0.023, p = 0.027); 0.016 (0.004 to 0.027, p = 0.008) and 0.005 (-0.005 to 0.016, p = 0.313) across the three measurement methods. Time to complete healing at 42 days yielded Hazard Ratios (unadjusted) of 1.3 (0.8 to 2.1, p = 0.300) assessed by unblinded local clinicians and 1.2 (0.7 to 2.0, p = 0.462) on blind assessment. CONCLUSION Any benefit from L-PRF appears insufficient to justify routine use in care of neuropathic ulcers in leprosy. TRIAL REGISTRATION ISRCTN14933421. Date of trial registration: 16 June 2020.
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Affiliation(s)
- Indra B. Napit
- Anandaban Hospital, The Leprosy Mission Nepal, Kathmandu, Nepal
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Dilip Shrestha
- Anandaban Hospital, The Leprosy Mission Nepal, Kathmandu, Nepal
| | - Sopna Choudhury
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Eleni Gkini
- Birmingham Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Onaedo Ilozumba
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Paramjit Gill
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Jon Bishop
- Birmingham Clinical Trials Unit, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Karuna Neupane
- Anandaban Hospital, The Leprosy Mission Nepal, Kathmandu, Nepal
| | - Anju Adhikari
- Anandaban Hospital, The Leprosy Mission Nepal, Kathmandu, Nepal
| | - Jo Sartori
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Samuel I. Watson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Richard Lilford
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
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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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Norman JE, Lawton J, Stock SJ, Siassakos D, Norrie J, Hallowell N, Chowdhry S, Hart RI, Odd D, Brewin J, Culshaw L, Lee-Davey C, Tebbutt H, Whyte S. Feasibility and design of a trial regarding the optimal mode of delivery for preterm birth: the CASSAVA multiple methods study. Health Technol Assess 2021; 25:1-102. [PMID: 34751645 DOI: 10.3310/hta25610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Around 60,000 babies are born preterm (prior to 37 weeks' gestation) each year in the UK. There is little evidence on the optimal birth mode (vaginal or caesarean section). OBJECTIVE The overall aim of the CASSAVA project was to determine if a trial to define the optimal mode of preterm birth could be carried out and, if so, determine what sort of trial could be conducted and how it could best be performed. We aimed to determine the specific groups of preterm women and babies for whom there are uncertainties about the best planned mode of birth, and if there would be willingness to recruit to, and participate in, a randomised trial to address some, but not all, of these uncertainties. This project was conducted in response to a Heath Technology Assessment programme commissioning call (17/22 'Mode of delivery for preterm infants'). METHODS We conducted clinician and patient surveys (n = 224 and n = 379, respectively) to identify current practice and opinion, and a consensus survey and Delphi workshop (n = 76 and n = 22 participants, respectively) to inform the design of a hypothetical clinical trial. The protocol for this clinical trial/vignette was used in telephone interviews with clinicians (n = 24) and in focus groups with potential participants (n = 13). RESULTS Planned sample size and data saturation was achieved for all groups except for focus groups with participants, as this had to be curtailed because of the COVID-19 pandemic and data saturation was not achieved. There was broad agreement from parents and health-care professionals that a trial is needed. The clinician survey demonstrated a variety of practice and opinion. The parent survey suggested that women and their families generally preferred vaginal birth at later gestations and caesarean section for preterm infants. The interactive workshop and Delphi consensus process confirmed the need for more evidence (hence the case for a trial) and provided rich information on what a future trial should entail. It was agreed that any trial should address the areas with most uncertainty, including the management of women at 26-32 weeks' gestation, with either spontaneous preterm labour (cephalic presentation) or where preterm birth was medically indicated. Clear themes around the challenges inherent in conducting any trial emerged, including the concept of equipoise itself. Specific issues were as follows: different clinicians and participants would be in equipoise for each clinical scenario, effective conduct of the trial would require appropriate resources and expertise within the hospital conducting the trial, potential participants would welcome information on the trial well before the onset of labour and minority ethnic groups would require tailored approaches. CONCLUSION Given the lack of evidence and the variation of practice and opinion in this area, and having listened to clinicians and potential participants, we conclude that a trial should be conducted and the outlined challenges resolved. FUTURE WORK The CASSAVA project could be used to inform the design of a randomised trial and indicates how such a trial could be carried out. Any future trial would benefit from a pilot with qualitative input and a study within a trial to inform optimal recruitment. LIMITATIONS Certainty that a trial could be conducted can be determined only when it is attempted. TRIAL REGISTRATION Current Controlled Trials ISRCTN12295730. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 61. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jane E Norman
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Julia Lawton
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Sarah J Stock
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Nina Hallowell
- Ethox Centre and Wellcome Centre for Ethics & Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Ruth I Hart
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - David Odd
- Division of Population Medicine, School of Medicine, University of Cardiff, Cardiff, UK
| | | | | | | | | | - Sonia Whyte
- Tommy's Centre for Maternal and Fetal Health, MRC Centre for Maternal and Fetal Health, University of Edinburgh, Edinburgh, UK
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Wald R, Bagshaw SM. Integration of Equipoise into Eligibility Criteria in the STARRT-AKI Trial. Am J Respir Crit Care Med 2021; 204:234-237. [PMID: 33939598 DOI: 10.1164/rccm.202009-3425le] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Ron Wald
- University of Toronto, Nephrology, Toronto, Ontario, Canada
| | - Sean M Bagshaw
- University of Alberta, Department of Critical Care Medicine, Edmonton, Alberta, Canada;
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Marshman Z, Kettle JE, Holmes RD, Cunningham KB, Freeman R, Gibson BJ, McColl E, Maguire A, Douglas GVA, Clarkson JE, Innes NPT. Dental professionals' experiences of managing children with carious lesions in their primary teeth - a qualitative study within the FiCTION randomised controlled trial. BMC Oral Health 2020; 20:64. [PMID: 32131801 PMCID: PMC7057668 DOI: 10.1186/s12903-020-1051-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 02/24/2020] [Indexed: 11/24/2022] Open
Abstract
Background The lack of evidence for the effective management of carious lesions in children’s primary teeth has caused uncertainty for the dental profession and patients. Possible approaches include conventional and biological management alongside best practice prevention, and best practice prevention alone. The FiCTION trial assessed the effectiveness of these options, and included a qualitative study exploring dental professionals’ (DPs) experiences of delivering the different treatment arms. This paper reports on how DPs managed children with carious lesions within FiCTION and how this related to their everyday experiences of doing dentistry. Methods Overall, 31 DPs from FiCTION-trained dental surgeries in four regions of the UK participated in semi-structured interviews about their experiences of the three treatment arms (conventional management of carious lesions and prevention (C + P), biological management of carious lesions and prevention (B + P) or prevention alone (PA)). A theoretical framework, drawing on social practice theory (SPT), was developed for analysis. Results Participants discussed perceived effectiveness of, and familiarity with, the three techniques. The C + P arm was familiar, but some participants questioned the effectiveness of conventional restorations. Attitudes towards the B + P arm varied in terms of familiarity, but once DPs were introduced to the techniques, this was seen as effective. While prevention was familiar, PA was described as ineffective. DPs manage children with carious lesions day-to-day, drawing on previous experience and knowledge of the child to provide what they view as the most appropriate treatment in the best interests of each child. Randomisation undermined these normal choices. Several DPs reported deviating from the trial arms in order to treat a patient in a particular way. Participants valued evidence-based dentistry, and expect to use the results of FiCTION to inform future practice. They anticipate continuing to use the full range of treatment options, and to personally select appropriate strategies for individual children. Conclusions RCTs take place in the context of day-to-day practices of doing dentistry. DPs employ experiential and interpersonal knowledge to act in the best interests of their patients. Randomisation within a clinical trial can present a source of tension for DPs, which has implications for assuring individual equipoise in future trials.
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Affiliation(s)
- Zoe Marshman
- School of Clinical Dentistry, Claremont Crescent, Sheffield, S10 2TA, UK
| | - Jennifer E Kettle
- School of Clinical Dentistry, Claremont Crescent, Sheffield, S10 2TA, UK
| | - Richard D Holmes
- School of Dental Sciences, Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Kathryn B Cunningham
- School of Medicine, University of St Andrews, North Haugh, St Andrews, KY16 9TF, UK
| | - Ruth Freeman
- Dental Health Services Research Unit, School of Dentistry, Park Place, Dundee, DD1 4HN, UK
| | - Barry J Gibson
- School of Clinical Dentistry, Claremont Crescent, Sheffield, S10 2TA, UK
| | - Elaine McColl
- Newcastle Clinical Trials Unit, 4th Floor, William Leech Building, Framlington Place, Newcastle Upon Tyne, NE2 4HH, UK
| | - Anne Maguire
- School of Dental Sciences, Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | | | - Janet E Clarkson
- Dental Health Services Research Unit, School of Dentistry, Park Place, Dundee, DD1 4HN, UK
| | - Nicola P T Innes
- School of Dentistry, University of Dundee, Park Place, Dundee, DD1 4HN, UK.
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Norris M, Poltawski L, Calitri R, Shepherd AI, Dean SG. Hope and despair: a qualitative exploration of the experiences and impact of trial processes in a rehabilitation trial. Trials 2019; 20:525. [PMID: 31443735 PMCID: PMC6708169 DOI: 10.1186/s13063-019-3633-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 08/08/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Unanticipated responses by research participants can influence randomised controlled trials (RCTs) in multiple ways, many of which are poorly understood. This study used qualitative interviews as part of an embedded process evaluation to explore the impact participants may have on the study, but also unintended impacts the study may have on them. AIM The aim of the study was to explore participants' experiences and the impact of trial involvement in a pilot RCT in order to inform the designing and delivery of a definitive RCT. METHODS In-depth interviews with 20 participants (10 in the intervention and 10 in the control group) enrolled in a stroke rehabilitation pilot trial. A modified framework approach was used to analyse transcripts. RESULTS Participation in the study was motivated partly by a desperation to receive further rehabilitation after discharge. Responses to allocation to the control group included an increased commitment to self-treatment, and negative psychological consequences were also described. Accounts of participants in both control and intervention groups challenge the presumption that they were neutral, or in equipoise, regarding group allocation prior to consenting to randomisation. CONCLUSIONS Considering and exploring participant and participation effects, particularly in the control group, highlights numerous issues in the interpretation of trial studies, as well as the in ethics of RCTs more generally. While suggestions for a definitive trial design are given, further research is required to investigate the significant implications these findings may have for trial design, monitoring and funding. TRIAL REGISTRATION ClinicalTrials.gov, NCT02429180 . Registered on 29 April/2015.
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Affiliation(s)
- Meriel Norris
- College of Health and Life Sciences, Brunel University London, Uxbridge, UB8 3PH UK
| | | | - Raff Calitri
- University of Exeter Medical School, Exeter, EX1 2LU UK
| | - Anthony I. Shepherd
- Department of Sport and Exercise Science, University of Portsmouth, Portsmouth, PO1 2ER UK
| | - Sarah G. Dean
- University of Exeter Medical School, Exeter, EX1 2LU UK
| | - on behalf of the ReTrain Team
- College of Health and Life Sciences, Brunel University London, Uxbridge, UB8 3PH UK
- University of Exeter Medical School, Exeter, EX1 2LU UK
- Department of Sport and Exercise Science, University of Portsmouth, Portsmouth, PO1 2ER UK
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Soomro N, Lecouturier J, Stocken DD, Shen J, Hynes AM, Ainsworth HF, Breen D, Oades G, Rix D, Aitchison M. Surveillance versus ablation for incidentally diagnosed small renal tumours: the SURAB feasibility RCT. Health Technol Assess 2019; 21:1-68. [PMID: 29280434 DOI: 10.3310/hta21810] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND There is uncertainty around the appropriate management of small renal tumours. Treatments include partial nephrectomy, ablation and active surveillance. OBJECTIVES To explore the feasibility of a randomised trial of ablation versus active surveillance. DESIGN Two-stage feasibility study: stage 1 - clinician survey and co-design work; and stage 2 - randomised feasibility study with qualitative and economic components. METHODS Stage 1 - survey of radiologists and urologists, and development of patient information materials. Stage 2 - patients identified across eight UK centres with small renal tumours (< 4 cm) were randomised (1 : 1 ratio) to ablation or active surveillance in an unblinded manner. Randomisation was carried out by a central computer system. The primary objective was to determine willingness to participate and to randomise a target of 60 patients. The qualitative and economic data were collected separately. RESULTS The trial was conducted across eight centres, with a site-specific period of recruitment ranging from 3 to 11 months. Of the 154 patients screened, 36 were eligible and were provided with study details. Seven agreed to be randomised and one patient was found ineligible following biopsy results. Six patients (17% of those eligible) were randomised: three patients received ablation and no serious adverse events were recorded. The 3- and 6-month data were collected for four (67%) and three (50%) out of the six patients, respectively. The qualitative substudy identified factors directly impacting on the recruitment of this trial. These included patient and clinician preferences, organisational factors (variation in clinical pathway) and standard treatment not included. The health economic questionnaire was designed and piloted; however, the sample size of recruited patients was insufficient to draw a conclusion on the feasibility of the health economics. CONCLUSIONS The trial did not meet the criteria for progression and the recruitment rate was lower than hypothesised, demonstrating that a full trial is presently not possible. The qualitative study identified factors that led to variation in recruitment across the sites. Implementation of organisational and operational measures can increase recruitment in any future trial. There was insufficient information to conduct a full economic analysis. TRIAL REGISTRATION Current Controlled Trials ISRCTN31161700. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 81. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Naeem Soomro
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jan Lecouturier
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Deborah D Stocken
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.,Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Jing Shen
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Marie Hynes
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Holly F Ainsworth
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - David Breen
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - David Rix
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Rooshenas L, Elliott D, Wade J, Jepson M, Paramasivan S, Strong S, Wilson C, Beard D, Blazeby JM, Birtle A, Halliday A, Rogers CA, Stein R, Donovan JL. Conveying Equipoise during Recruitment for Clinical Trials: Qualitative Synthesis of Clinicians' Practices across Six Randomised Controlled Trials. PLoS Med 2016; 13:e1002147. [PMID: 27755555 PMCID: PMC5068710 DOI: 10.1371/journal.pmed.1002147] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 09/07/2016] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) are essential for evidence-based medicine and increasingly rely on front-line clinicians to recruit eligible patients. Clinicians' difficulties with negotiating equipoise is assumed to undermine recruitment, although these issues have not yet been empirically investigated in the context of observable events. We aimed to investigate how clinicians conveyed equipoise during RCT recruitment appointments across six RCTs, with a view to (i) identifying practices that supported or hindered equipoise communication and (ii) exploring how clinicians' reported intentions compared with their actual practices. METHODS AND FINDINGS Six pragmatic UK-based RCTs were purposefully selected to include several clinical specialties (e.g., oncology, surgery) and types of treatment comparison. The RCTs were all based in secondary-care hospitals (n = 16) around the UK. Clinicians recruiting to the RCTs were interviewed (n = 23) to understand their individual sense of equipoise about the RCT treatments and their intentions for communicating equipoise to patients. Appointments in which these clinicians presented the RCT to trial-eligible patients were audio-recorded (n = 105). The appointments were analysed using thematic and content analysis approaches to identify practices that supported or challenged equipoise communication. A sample of appointments was independently coded by three researchers to optimise reliability in reported findings. Clinicians and patients provided full written consent to be interviewed and have appointments audio-recorded. Interviews revealed that clinicians' sense of equipoise varied: although all were uncertain about which trial treatment was optimal, they expressed different levels of uncertainty, ranging from complete ambivalence to clear beliefs that one treatment was superior. Irrespective of their personal views, all clinicians intended to set their personal biases aside to convey trial treatments neutrally to patients (in accordance with existing evidence). However, equipoise was omitted or compromised in 48/105 (46%) of the recorded appointments. Three commonly recurring practices compromised equipoise communication across the RCTs, irrespective of clinical context. First, equipoise was overridden by clinicians offering treatment recommendations when patients appeared unsure how to proceed or when they asked for the clinician's expert advice. Second, clinicians contradicted equipoise by presenting imbalanced descriptions of trial treatments that conflicted with scientific information stated in the RCT protocols. Third, equipoise was undermined by clinicians disclosing their personal opinions or predictions about trial outcomes, based on their intuition and experience. These broad practices were particularly demonstrated by clinicians who had indicated in interviews that they held less balanced views about trial treatments. A limitation of the study was that clinicians volunteering to take part in the research might have had a particular interest in improving their communication skills. However, the frequency of occurrence of equipoise issues across the RCTs suggests that the findings are likely to be reflective of clinical recruiters' practices more widely. CONCLUSIONS Communicating equipoise is a challenging process that is easily disrupted. Clinicians' personal views about trial treatments encroached on their ability to convey equipoise to patients. Clinicians should be encouraged to reflect on personal biases and be mindful of the common ways in which these can arise in their discussions with patients. Common pitfalls that recurred irrespective of RCT context indicate opportunities for specific training in communication skills that would be broadly applicable to a wide clinical audience.
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Affiliation(s)
- Leila Rooshenas
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Daisy Elliott
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Julia Wade
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Marcus Jepson
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Sangeetha Paramasivan
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Sean Strong
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Caroline Wilson
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Jane M. Blazeby
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Alison Birtle
- Rosemere Cancer Centre, Royal Preston Hospital, Preston, United Kingdom
| | | | - Chris A. Rogers
- Clinical Trials and Evaluation Unit, Bristol Royal Infirmary, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Rob Stein
- University College London Hospitals, London, United Kingdom
| | - Jenny L. Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Trust, Bristol, United Kingdom
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Byrne MM, Thompson P. Collective Equipoise, Disappointment, and the Therapeutic Misconception: On the Consequences of Selection for Clinical Research. Med Decis Making 2016; 26:467-79. [PMID: 16997925 DOI: 10.1177/0272989x06290499] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Private information induces individuals to self-select as subjects into clinical research trials, and it induces researchers to select which trials they conduct. The authors show that selection can induce ex ante therapeutic misconception and ex post disappointment among research subjects, and it undermines the rationale of collective equipoise as an ethical basis for clinical trials. Selection provides a reason to make nontrivial payments to subjects, and it implies that researchers should not design experiments to maximize statistical power.
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Affiliation(s)
- Margaret M Byrne
- Department of Epidemiology and Public Health, University of Miami, Florida 33101, USA.
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Katz JN, Losina E, Lohmander LS. OARSI Clinical Trials Recommendations: Design and conduct of clinical trials of surgical interventions for osteoarthritis. Osteoarthritis Cartilage 2015; 23:798-802. [PMID: 25952350 PMCID: PMC4703308 DOI: 10.1016/j.joca.2015.02.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 02/17/2015] [Accepted: 02/20/2015] [Indexed: 02/02/2023]
Abstract
To highlight methodological challenges in the design and conduct of randomized trials of surgical interventions and to propose strategies for addressing these challenges. This paper focuses on three broad areas: enrollment; intervention; and assessment including implications for analysis. For each challenge raised in the paper, we propose potential solutions. Enrollment poses challenges in maintaining investigator equipoise, managing conflict of interest and anticipating that patient preferences for specific treatments may reduce enrollment. Intervention design and implementation pose challenges relating to obsolescence, fidelity of intervention delivery, and adherence and crossover. Assessment and analysis raise questions regarding blinding and clustering of observations. This paper describes methodological problems in the design and conduct of surgical randomized trials and proposes strategies for addressing these challenges.
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Affiliation(s)
- J N Katz
- Department of Orthopedic Surgery and Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Harvard Medical School, USA.
| | - E Losina
- Department of Orthopedic Surgery and Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Harvard Medical School, USA
| | - L S Lohmander
- Department of Orthopedic Surgery, Clinical Sciences Lund, Lund University, Sweden; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Denmark; Department of Orthopedics and Traumatology, University of Southern Denmark, Denmark
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11
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Shamy MCF, Stahnisch FW, Hill MD. Fallibility: A New Perspective on the Ethics of Clinical Trial Enrollment. Int J Stroke 2014; 10:2-6. [DOI: 10.1111/ijs.12376] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 09/10/2014] [Indexed: 11/30/2022]
Abstract
The ethical principle of ‘equipoise’, introduced in 1974, represents the most widely influential justification for the enrollment of patients into randomized clinical trials. However, definitions of equipoise vary, and its terms are not universally accepted. In this paper, we suggest a new way of approaching the ethics of clinical trial enrollment, which we call fallibility. The principle of fallibility argues that all physician opinions are sufficiently uncertain to warrant investigation, and that the ethical justification for any trial becomes a question of its epistemic validity, by which we mean the strength of its hypotheses and methods. The principle of fallibility can be translated into practice through the virtues of humility, skepticism and caring. While we cite recent examples from stroke medicine to demonstrate the limitations of equipoise, we propose that fallibility may offer a more general means of addressing the controversies that arise surrounding randomized controlled trials in many disciplines of medicine.
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Affiliation(s)
- Michel C. F. Shamy
- Department of Medicine (Neurology), University of Ottawa, Ottawa, ON, Canada
| | - Frank W. Stahnisch
- Department of History, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Michael D. Hill
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
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Dunbar J, Hernan A, Janus E, Davis-Lameloise N, Asproloupos D, O'Reilly S, Timoshanko A, Stewart E, Bennett CM, Johnson G, Carter R. Implementation salvage experiences from the Melbourne diabetes prevention study. BMC Public Health 2012; 12:806. [PMID: 22992417 PMCID: PMC3577485 DOI: 10.1186/1471-2458-12-806] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 09/17/2012] [Indexed: 01/17/2023] Open
Abstract
Background Many public health interventions based on apparently sound evidence from randomised controlled trials encounter difficulties when being scaled up within health systems. Even under the best of circumstances, implementation is exceedingly difficult. In this paper we will describe the implementation salvage experiences from the Melbourne Diabetes Prevention Study, which is a randomised controlled trial of the effectiveness and cost-effectiveness nested in the state-wide Life! Taking Action on Diabetes program in Victoria, Australia. Discussion The Melbourne Diabetes Prevention Study sits within an evolving larger scale implementation project, the Life! program. Changes that occurred during the roll-out of that program had a direct impact on the process of conducting this trial. The issues and methods of recovery the study team encountered were conceptualised using an implementation salvage strategies framework. The specific issues the study team came across included continuity of the state funding for Life! program and structural changes to the Life! program which consisted of adjustments to eligibility criteria, referral processes, structure and content, as well as alternative program delivery for different population groups. Staff turnover, recruitment problems, setting and venue concerns, availability of potential participants and participant characteristics were also identified as evaluation roadblocks. Each issue and corresponding salvage strategy is presented. Summary The experiences of conducting such a novel trial as the preliminary Melbourne Diabetes Prevention Study have been invaluable. The lessons learnt and knowledge gained will inform the future execution of this trial in the coming years. We anticipate that these results will also be beneficial to other researchers conducting similar trials in the public health field. We recommend that researchers openly share their experiences, barriers and challenges when conducting randomised controlled trials and implementation research. We encourage them to describe the factors that may have inhibited or enhanced the desired outcomes so that the academic community can learn and expand the research foundation of implementation salvage.
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Affiliation(s)
- James Dunbar
- Greater Green Triangle University Department of Rural Health, Flinders University and Deakin University, Warrnambool, VIC 3280, Australia.
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Lie M, May C, Kelly T, Robson S. 'Let the computer choose?': the experience of participants in a randomised preference trial of medical versus surgical termination of pregnancy. SOCIOLOGY OF HEALTH & ILLNESS 2012; 34:746-760. [PMID: 22118291 DOI: 10.1111/j.1467-9566.2011.01412.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The termination of pregnancy trial (Newcastle upon Tyne, UK), is the only randomised trial on termination of pregnancy methods incorporating a qualitative element that aimed to understand the experiences of women participating in the trial. Based on the results of this qualitative work, this article aims to provide insights into two strands of understanding; firstly, women's experience of participating in research about abortion and secondly, their experience of participating in a randomised preference trial. Semi-structured interviews were conducted of up to 90 minutes with 30 participants recruited at a single hospital site. A total of 20 women from the preference arm and 10 from the random arm were interviewed. The analysis and discussion of our findings use reflexive modernisation as a framework for understanding and interpreting some of the actions of social agents, that is, the participants and trial recruiters in the course of a clinical trial as an expert system. We found that the factors that shape women's experiences and decisions include trust in the expert system and reflexivity and agency on the part of both participants and trial recruiters.
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Affiliation(s)
- Mabel Lie
- Institute of Health and Society, Newcastle University Faculty of Health Sciences, University of Southampton Institute of Cellular Medicine, Newcastle University, Richardson Road, Newcastle upon Tyne.
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14
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Parsons NR, Kulikov Y, Girling A, Griffin D. A statistical framework for quantifying clinical equipoise for individual cases during randomized controlled surgical trials. Trials 2011; 12:258. [PMID: 22166100 PMCID: PMC3261829 DOI: 10.1186/1745-6215-12-258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 12/13/2011] [Indexed: 12/28/2022] Open
Abstract
Background Randomised controlled trials are being increasingly used to evaluate new surgical interventions. There are a number of problematic methodological issues specific to surgical trials, the most important being identifying whether patients are eligible for recruitment into the trial. This is in part due to the diversity in practice patterns across institutions and the enormous range of available interventions that often leads to a low level of agreement between clinicians about both the value and the appropriate choice of intervention. We argue that a clinician should offer patients the option of recruitment into a trial, even if the clinician is not individually in a position of equipoise, if there is collective (clinical) equipoise amongst the wider clinical community about the effectiveness of a proposed intervention (the clinical equipoise principle). We show how this process can work using data collected from an ongoing trial of a surgical intervention. Results We describe a statistical framework for the assessment of uncertainty prior to patient recruitment to a clinical trial using a panel of expert clinical assessors and techniques for eliciting, pooling and modelling of expert opinions. The methodology is illustrated using example data from the UK Heel Fracture Trial. The statistical modelling provided results that were clear and simple to present to clinicians and showed how decisions regarding recruitment were influenced by both the collective opinion of the expert panel and the type of decision rule selected. Conclusions The statistical framework presented has potential to identify eligible patients and assist in the simplification of eligibility criteria which might encourage greater participation in clinical trials evaluating surgical interventions.
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Abstract
The authors look back at the five decades of radiation oncology and consider how one's choices and decisions influence how a career is pursued and how a professional life is lived. Accomplishments and contributions in a career in radiation oncology, and in medicine in general, involve individual choices that impact the direction of a specialty, decisions in patient care, consequences of treatment outcome, and personal satisfaction. Issues in radiation oncology include: the development and implementation of new radiation treatment technology; the use of multimodality and biologically based therapies; the role of nonradiation “energy” technologies, often by other medical specialties, including the need for quality assurance in treatment and data reporting; and the type of evidence, including appropriate study design, analysis, and rigorous long-term follow-up, that is sought before widespread implementation of a new treatment. Personal choices must weigh: the pressure from institutions—practices, departments, universities, and hospitals; the need to serve society and the underserved; the balance between individual reward and a greater mission; and the critical role of personal values and integrity, often requiring difficult and “life-defining” decisions. The impact that each of us makes in a career is perhaps more a result of character than of the specific details enumerated on one's curriculum vitae. The individual tapestry weaved by choosing the more or less traveled paths during a career results in many pathways that would be called success; however, the one path for which there is no good alternative is that of living and acting with integrity.
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Affiliation(s)
- C Norman Coleman
- Radiation Research Program, 6130 Executive Boulevard, Bethesda, Maryland 20892, USA.
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Katz JN, Wright J, Levy BA, Baron JA, Losina E. Departures from community equipoise may lead to incorrect inference in randomized trials. J Clin Epidemiol 2010; 64:280-5. [PMID: 20638236 DOI: 10.1016/j.jclinepi.2010.04.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2009] [Revised: 03/18/2010] [Accepted: 04/04/2010] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To assess the impact of selective enrollment on the results of randomized controlled trials (RCTs). STUDY DESIGN AND SETTING We simulated an RCT of arthroscopic partial meniscectomy vs. nonoperative therapy in patients with meniscal tear and osteoarthritis (OA). We estimated efficacy with the risk ratio (RR) comparing the likelihood of clinically important improvement after surgery with that after nonoperative therapy. We assumed that efficacy differs by extent of OA. We simulated four scenarios: (1) nonselective enrollment; (2) higher likelihood of enrolling subjects with mild OA; (3) higher likelihood of enrolling subjects with severe OA; (4) much higher likelihood of enrolling subjects with severe OA. For each scenario, we simulated 100 trials with sample size 340. RESULTS With nonselective enrollment, reflecting community equipoise, the results in 100 trials were consistent with those in the underlying population (mean RR: 1.87; 95% confidence interval [95% CI]: 1.57, 2.14). Selective enrollment of subjects with much higher likelihood of severe OA resulted in 28% lower efficacy of surgery (mean RR: 1.34; 95% CI: 0.93, 2.15), with 95% CI containing the true efficacy in just 25% of trials and empirical power of 44%. CONCLUSION Selective enrollment with respect to factors associated with efficacy may affect trial results and lead to inaccurate conclusions.
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Affiliation(s)
- Jeffrey N Katz
- Department of Orthopaedic Surgery, Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Winzer A, Hoppe A, Altenhoff J, Kuwert C, Koch U, Schulz H. Interest in a psycho-educational group intervention among out-patients with malignant melanoma in relation to their need: which patients are likely to participate? Psychooncology 2010; 18:1179-88. [PMID: 19360695 DOI: 10.1002/pon.1164] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The aim of this study was to examine the interest which patients with malignant melanoma may have in a six week psycho-educational group intervention and determine factors that are associated with their degree of interest. Of 144 outpatients, 121 (84%) agreed to participate in the interview (78 women, 66 men, mean age 59, SD=15; mean time since surgery=57 months, SD=55). About one-third (29%) of the sample had either nodal or in-transit metastases. A semi-structured interview was conducted to assess patients' interest (perceived need) in the intervention. We administered the Hornheide questionnaire and other psychosocial measures to identify highly distressed patients (expert-defined need). Lower age, being male, having no partner and lower cognitive avoidance emerged as significant predictors for a general interest in the intervention (n=92). A substantial number of patients (42.5%) stated a willingness to participate in the intervention at that time. Two problematic subgroups could be identified in the sample: patients in an expert-defined need of support who lacked any interest ('avoiders') and interested patients without an expert-defined need ('skilled help-seekers'). In order to achieve consistent results when conducting future interventions, the interventions should either be limited to patients with expert-defined need or patients should be carefully controlled for this variable.
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Affiliation(s)
- Alexandra Winzer
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
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Djulbegovic B. The paradox of equipoise: the principle that drives and limits therapeutic discoveries in clinical research. Cancer Control 2009; 16:342-7. [PMID: 19910921 PMCID: PMC2782889 DOI: 10.1177/107327480901600409] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Progress in clinical medicine relies on the willingness of patients to take part in experimental clinical trials, particularly randomized controlled trials (RCTs). Before agreeing to enroll in clinical trials, patients require guarantees that they will not knowingly be harmed and will have the best possible chances of receiving the most favorable treatments. This guarantee is provided by the acknowledgment of uncertainty (equipoise), which removes ethical dilemmas and makes it easier for patients to enroll in clinical trials. METHODS Since the design of clinical trials is mostly affected by clinical equipoise, the "clinical equipoise hypothesis" has been postulated. If the uncertainty requirement holds, this means that investigators cannot predict what they are going to discover in any individual trial that they undertake. In some instances, new treatments will be superior to standard treatments, while in others, standard treatments will be superior to experimental treatments, and in still others, no difference will be detected between new and standard treatments. It is hypothesized that there must be a relationship between the overall pattern of treatment successes and the uncertainties that RCTs are designed to address. RESULTS An analysis of published trials shows that the results cannot be predicted at the level of individual trials. However, the results also indicate that the overall pattern of discovery of treatment success across a series of trials is predictable and is consistent with clinical equipoise hypothesis. The analysis shows that we can discover no more than 25% to 50% of successful treatments when they are tested in RCTs. The analysis also indicates that this discovery rate is optimal in helping to preserve the clinical trial system; a high discovery rate (eg, a 90% to 100% probability of success) is neither feasible nor desirable since under these circumstances, neither the patient nor the researcher has an interest in randomization. This in turn would halt the RCT system as we know it. CONCLUSIONS The "principle or law of clinical discovery" described herein predicts the efficiency of the current system of RCTs at generating discoveries of new treatments. The principle is derived from the requirement for uncertainty or equipoise as a precondition for RCTs, the precept that paradoxically drives discoveries of new treatments while limiting the proportion and rate of new therapeutic discoveries.
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Affiliation(s)
- Benjamin Djulbegovic
- Center for Evidence-Based Medicine and Health Outcomes Research and the Clinical Translational Science Institute, the University of South Florida, Tampa, Florida 33612, USA.
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Wade J, Donovan JL, Lane JA, Neal DE, Hamdy FC. It's not just what you say, it's also how you say it: opening the 'black box' of informed consent appointments in randomised controlled trials. Soc Sci Med 2009; 68:2018-28. [PMID: 19364625 DOI: 10.1016/j.socscimed.2009.02.023] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Indexed: 11/28/2022]
Abstract
Randomised controlled trials (RCTs) represent the gold standard methodology for determining effectiveness of healthcare interventions. Poor recruitment to RCTs can threaten external validity and waste resources. An inherent tension exists between safeguarding informed decision-making by participants and maximising numbers enrolled. This study investigated what occurs during informed consent appointments in an ongoing multi-centre RCT in the UK. Objectives were to investigate: 1] how study staff presented study information to participants; 2] what evidence emerged as to how well-informed participants were when proceeding to randomisation or treatment selection; and 3] what aspects of the communication process may facilitate improvements in providing evidence of informed consent. Qualitative analysis of a purposive sample of 23 recruitment appointments from three study centres and involving several recruitment staff applied techniques of thematic, content and conversation analysis (CA). Thematic analysis and CA revealed variation in appointment content and structure. Appointments were mostly recruiter-led or participant-led, and this structure was associated with what evidence emerged as to how participants understood information provided and whether they were in equipoise. Participant-led appointments provided this evidence more consistently. Detailed CA identified communication techniques which, when employed by recruiters, provided evidence as to how participants understood the choices before them. Strategic use of open questions, pauses and ceding the floor in the interaction facilitated detailed and systematic exploration of each participant's concerns and position regarding equipoise. We conclude that the current focus on content to be provided to achieve informed consent should be broadened to encompass consideration of how information is best conveyed to potential participants. A model of tailored information provision using the communication techniques identified and centred on eliciting and addressing participants' concerns is proposed. Use of these techniques is necessary to make potential participants' understanding of key issues and their position regarding equipoise explicit in order to facilitate truly informed consent.
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Affiliation(s)
- Julia Wade
- Department of Social Medicine, University of Bristol, 39 Whatley Road, Clifton, Bristol BS8 2PS, United Kingdom.
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20
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Stadhouder A, Oner FC, Wilson KW, Vaccaro AR, Williamson OD, Verbout AJ, Verhaar JA, de Klerk LWL, Buskens E. Surgeon equipoise as an inclusion criterion for the evaluation of nonoperative versus operative treatment of thoracolumbar spinal injuries. Spine J 2008; 8:975-81. [PMID: 18261964 DOI: 10.1016/j.spinee.2007.11.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Revised: 10/13/2007] [Accepted: 11/12/2007] [Indexed: 02/09/2023]
Abstract
BACKGROUND CONTEXT Prospective studies have failed to demonstrate the superiority of either operative or nonoperative treatment of thoracolumbar fractures. Similar to other surgical fields, research has been limited by the variability in surgical interventions, difficult recruitment, infrequent pathology, and the urgency of interventions. PURPOSE To outline factors precluding randomized controlled trials in spinal fractures research, and describe a novel methodology that seeks to improve on the design of observational studies. STUDY DESIGN/SETTING A preliminary report describing an observational study design with clinical equipoise as an inclusion criterion. The proposed methodology is a cohort study with head-to-head comparison of operative and nonoperative treatment regimens in an expertise-based trial fashion. Patients are selected retrospectively by an expert panel and clinical outcomes are assessed to compare competing treatment regimens. Surgeon equipoise served as an inclusion criterion. PATIENT SAMPLE Patients with closed or open thoracolumbar spinal fracture with or without neurological impairment, presenting to one of two different trauma centers between 1991 and 2005 (N = 760). OUTCOME MEASURES Homogeneity of baseline clinical and demographic data and distribution of prognostic risk factors between the operative and the nonoperative cohort. METHODS Patients treated for spine fractures at two University hospitals practicing opposing methods of fracture intervention were identified by medical diagnosis code searches (n = 760). A panel of spine treatment experts, blinded to the treatment received clinically has assessed each case retrospectively. Patients were included in the study when there was disagreement on the preferred treatment, that is, operative or nonoperative treatment of the injury. Baseline and initial data of a study evaluating nonoperative versus operative spinal fracture treatment are presented. RESULTS One hundred and ninety patients were included in the study accounting for a panel discordance rate of 29%. The distribution of baseline characteristics and demographics of the study populations were equal across the parallel cohorts enrolled in the study, that is, no differences in prognostic factors were observed. CONCLUSIONS The use of clinical equipoise as an inclusion criterion in comparative studies may be used to avoid selection bias. Using multivariate analysis of retrospectively assembled parallel cohorts, a valid comparison of operative and nonoperative spine fracture treatment strategies and their outcomes is possible.
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Affiliation(s)
- A Stadhouder
- Department of Orthopaedic Surgery, University Medical Centre Utrecht, Heidelberglaan 100, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
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Abstract
BACKGROUND Human biomonitoring (HBM) has rapidly gained importance. In some epidemiological studies, the measurement and use of biomarkers of exposure, susceptibility and disease have replaced traditional environmental indicators. While in HBM, ethical issues have mostly been addressed in terms of informed consent and confidentiality, this paper maps out a larger array of societal issues from an epistemological perspective, i.e. bringing into focus the conditions of how and what is known in environmental health science. METHODS In order to analyse the effects of HBM and the shift towards biomarker research in the assessment of environmental pollution in a broader societal context, selected analytical frameworks of science studies are introduced. To develop the epistemological perspective, concepts from "biomedical platform sociology" and the notion of "epistemic cultures" and "thought styles" are applied to the research infrastructures of HBM. Further, concepts of "biocitizenship" and "civic epistemologies" are drawn upon as analytical tools to discuss the visions and promises of HBM as well as related ethical problematisations. RESULTS In human biomonitoring, two different epistemological cultures meet; these are environmental science with for instance pollution surveys and toxicological assessments on the one hand, and analytical epidemiology investigating the association between exposure and disease in probabilistic risk estimation on the other hand. The surveillance of exposure and dose via biomarkers as envisioned in HBM is shifting the site of exposure monitoring to the human body. Establishing an HBM platform faces not only the need to consider individual decision autonomy as an ethics issue, but also larger epistemological and societal questions, such as the mode of evidence demanded in science, policy and regulation. CONCLUSION The shift of exposure monitoring towards the biosurveillance of human populations involves fundamental changes in the ways environment, health and disease are conceptualised; this may lead to an individualisation of responsibilities for health risks and preventive action. Attention to the conditions of scientific knowledge generation and to their broader societal context is critical in order to make HBM contribute to environmental justice.
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Affiliation(s)
- Susanne Bauer
- Medical Museion, Faculty of Health Sciences, University of Copenhagen, Fredericiagade 18, DK-1310 Copenhagen, Denmark.
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Aarts MAW, Granton J, Cook DJ, Bohnen JMA, Marshall JC. Empiric Antimicrobial Therapy in Critical Illness: Results of a Surgical Infection Society Survey. Surg Infect (Larchmt) 2007; 8:329-36. [PMID: 17635055 DOI: 10.1089/sur.2006.072] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Antibiotics are prescribed commonly in the intensive care unit (ICU). Often, therapy is initiated empirically; practice patterns are not well characterized. We documented approaches to empiric antibiotic therapy among members of the Surgical Infection Society (SIS). METHODS We sent a scenario-based questionnaire to all SIS members. The hypothetical cases addressed empiric broad-spectrum therapy for a patient with pyrexia and leukocytosis and the use of vancomycin for central venous catheter infection. RESULTS The 113 respondents were primarily surgeons (96%) with a university-based practice (92%). Most attended in the ICU (72%), and they had practiced for 14 +/- 8 years. Whereas 63% of the respondents identified overuse of antibiotics as a problem in their ICU, only 19% said inadequate treatment of infection was a concern. For a febrile patient with negative cultures who was receiving antibiotics, estimates of the likelihood of infection increased across the three scenarios as the degree of organ failure increased (p < 0.0001; chi-square test). Deteriorating organ function was associated with a decision to broaden empiric therapy (58% vs. 33%; p < 0.0001) and to initiate anti-fungal therapy (27% vs. 9%; p < 0.0001) rather than to stop antibiotics and re-culture (15% vs. 51%; p < 0.0001). There was considerable variability in management strategy across the scenarios: Even in the face of organ dysfunction, 58% of physicians would add or change empiric therapy, whereas 30% would not. For each scenario, 23 to 25 antibiotic regimens were designated as optimal therapy. Only 45% of the respondents would initiate empiric vancomycin for suspected central line infection. Variability in approach was not explained by critical care practice, academic position, or country. CONCLUSIONS Clinical deterioration is a strong determinant of a decision to initiate or broaden empiric antibiotic therapy during critical illness. The substantial variability in approach suggests a state of clinical equipoise that calls for more rigorous evaluation through a randomized controlled trial.
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Affiliation(s)
- Mary-Anne W Aarts
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Ghogawala Z, Coumans JV, Benzel EC, Stabile LM, Barker FG. Ventral versus dorsal decompression for cervical spondylotic myelopathy: surgeons' assessment of eligibility for randomization in a proposed randomized controlled trial: results of a survey of the Cervical Spine Research Society. Spine (Phila Pa 1976) 2007; 32:429-36. [PMID: 17304133 DOI: 10.1097/01.brs.0000255068.94058.8a] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Surgeons attending a Cervical Spine Research Society (CSRS) meeting were surveyed about the surgical approach to cervical spondylotic myelopathy (CSM). OBJECTIVE To elicit spine surgeons' opinions on the suitability of a panel of test cases for randomization in a proposed randomized controlled trial (RCT) of ventral versus dorsal decompression for CSM. SUMMARY OF BACKGROUND DATA The optimal surgical decompression strategy for CSM has not been defined. Specific eligibility criteria should be defined before a RCT is initiated. METHODS Twenty actual cases with images were prepared. Surgeons supplied demographic information, preferred surgical approach, and eligibility for randomization for 10 cases. RESULTS A total of 91 of 239 (38%) surgeons completed the survey. Of 900 case-strategy responses, 51% recommended ventral surgery, 38% dorsal surgery, and 11% a combined approach. Both overall C2-C7 kyphosis >5 degrees and a segmental kyphotic deformity were inversely correlated with eligibility for randomization (P < 0.001 for both). Using these 2 criteria plus age over 85 years, ossification of the posterior longitudinal ligament, and congenital canal stenosis as additional exclusion criteria, 12 of 20 survey cases were considered potentially eligible for randomization. Orthopedic and neurologic surgeons were similar in determining a case's eligibility for randomization. CONCLUSIONS These results measure surgeons' opinions on the suitability of cases for randomization and help to define entry and exclusion criteria for a RCT comparing ventral to dorsal strategies. Over 50% of CSM cases from a general spinal practice might be eligible for randomization.
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Affiliation(s)
- Zoher Ghogawala
- Department of Neurosurgery, Wallace Clinical Trials Center, Yale University School of Medicine, Greenwich Hospital, Greenwich, CT 06830, USA.
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Canvin K, Jacoby A. Duty, desire or indifference? A qualitative study of patient decisions about recruitment to an epilepsy treatment trial. Trials 2006; 7:32. [PMID: 17163988 PMCID: PMC1770934 DOI: 10.1186/1745-6215-7-32] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2006] [Accepted: 12/12/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Epilepsy is a common neurological condition, in which drugs are the mainstay of treatment and drugs trials are commonplace. Understanding why patients might or might not opt to participate in epilepsy drug trials is therefore of some importance, particularly at a time of rapid drug development and testing; and the findings may also have wider applicability. This study examined the role of patient perceptions in the decision-making process about recruitment to an RCT (the SANAD Trial) that compared different antiepileptic drug treatments for the management of new-onset seizures and epilepsy. METHODS In-depth interviews with 23 patients recruited from four study centres. All interviews were tape-recorded and transcribed; the transcripts were analysed thematically using a qualitative data analysis package. RESULTS Of the nineteen informants who agreed to participate in SANAD, none agreed for purely altruistic reasons. The four informants who declined all did so for very specific reasons of self-interest. Informants' perceptions of the nature of the trial, of the drugs subject to trial, and of their own involvement were all highly influential in their decision-making. Informants either perceived the trial as potentially beneficial or unlikely to be harmful, and so agreed to participate; or as potentially harmful or unlikely to be beneficial and so declined to participate. CONCLUSION Most patients applied 'weak altruism', while maintaining self-interest. An emphasis on the safety and equivalence of treatments allowed some patients to be indifferent to the question of involvement. There was evidence that some participants were subject to 'therapeutic misconceptions'. The findings highlight the individual nature of trials but nonetheless raise some generic issues in relation to their design and conduct.
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Affiliation(s)
- Krysia Canvin
- Division of Public Health, University of Liverpool, Liverpool, UK
| | - Ann Jacoby
- Division of Public Health, University of Liverpool, Liverpool, UK
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Wallace K, Fleshner N, Jewett M, Basiuk J, Crook J. Impact of a Multi-Disciplinary Patient Education Session on Accrual to a Difficult Clinical Trial: The Toronto Experience With the Surgical Prostatectomy Versus Interstitial Radiation Intervention Trial. J Clin Oncol 2006; 24:4158-62. [PMID: 16943531 DOI: 10.1200/jco.2006.06.3875] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Random assignment to clinical trials involving different treatment modalities can be difficult. We describe our experience with the Surgical Prostatectomy Versus Interstitial Radiation Intervention Trial (SPIRIT; ACOSOG Z0070 NCIC PR10), a randomized trial for early-stage prostate cancer comparing radical prostatectomy (RP), and brachytherapy (BT). A multidisciplinary educational session was developed to improve patient understanding of treatment options and to facilitate accrual. Patients and Methods Prostate cancer referrals were screened and men who met favorable risk criteria (T1c/T2a, prostate-specific antigen [PSA] < 10 ng/mL, Gleason ≤ 6) were invited to a structured education session before a specialty consultation. Men and their partners viewed the SPIRIT informed-consent video and heard from a cancer patient who described his participation in a randomized trial. Then, a urologist and radiation oncologist together compared and contrasted RP and BT to establish the rationale for the trial. Results In May 2002, SPIRIT opened for accrual and was endorsed by the University Health Network urologists and radiation oncologists. The first 27 eligible patients were approached about SPIRIT, consulted both specialties, and viewed an educational video. No patients consented. The multidisciplinary education session was then introduced. Forty-seven education sessions with 263 patients resulted in 34 consents. Of 203 patients who were suitable for the study but declined random assignment, 62 chose surgery, 94 chose brachytherapy, three patients chose external radiotherapy, and 11 chose no treatment. Consent rates for eligible and suitable patients were one in six. Conclusion Men who understand their treatment options and trial rationale as presented jointly by representative specialists from competing treatment modalities may be better equipped to make an informed decision and are more likely to consent to random assignment.
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Affiliation(s)
- Kris Wallace
- Department of Radiation Medicine and the Division of Urology, Princess Margaret Hospital, University Health Network, Toronto, Canada
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Garcia J, Elbourne D, Snowdon C. Equipoise: a case study of the views of clinicians involved in two neonatal trials. Clin Trials 2006; 1:170-8. [PMID: 16281889 DOI: 10.1191/1740774504cn020xx] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND It is considered to be a fundamental ethical premise of human experimentation, that it should be carried out only where the effects of an intervention are unclear. The point at which it is considered that there is insufficient scientific and medical evidence to clearly state the superiority of an intervention has been termed equipoise. This concept has been the subject of much recent impassioned debate but little empirical research about the views of people involved in recruitment to randomized controlled trials (RCTs), and none in the particularly emotive area of neonatal intensive care. METHODS Thirty neonatologists recruiting into one or both of two neonatal RCTs in five centres in England were interviewed using a semi-structured schedule to explore their involvement in randomised trials. The interviews were tape-recorded and transcribed. Equipoise was one among a range of topics covered. Concepts relating to equipoise were identified by close reading of the entire interviews. Themes emerging from the data were noted in their contexts then discussed between the co-authors. Interviewees also completed a brief questionnaire about their demographic background, and their experience of research and RCTs. RESULTS Almost all the neonatologists used the concept of equipoise [using words and phrases such as uncertainty, lack of knowledge (or ignorance), strengths of views, and balancing of pros and cons] in their interview and, for most of them, equipoise seemed to be a useful term. They explored ideas about equipoise at the individual and community levels, and some linked equipoise with notions of the responsibility that should be exercised by the scientific and professional communities. They differed in the importance they gave to individual equipoise, and in how they reacted to threats to equipoise. Feelings of doubt about a trial and disturbed equipoise were more often expressed by more junior doctors. CONCLUSIONS Our findings suggest that the concept of equipoise goes beyond the idea of uncertainty. In part this is because it includes the balancing of benefit and harm; this balancing is part of a professional obligation and requires engagement with 'expert' knowledge. Equipoise could therefore be seen as 'active' or 'responsible' uncertainty. Elucidation of this difficult concept may help to facilitate recruitment for both clinicians and parents in future trials and thereby help to find answers to important clinical questions.
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Affiliation(s)
- Jo Garcia
- Medical Statistics Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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Harrison JD, Carter J, Young JM, Solomon MJ. Difficult clinical decisions in gynecological oncology: identifying priorities for future clinical research. Int J Gynecol Cancer 2006; 16:1-7. [PMID: 16445602 DOI: 10.1111/j.1525-1438.2006.00424.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
This study investigates the acceptability and feasibility of conducting randomized controlled trials (RCTs) in gynecological oncology by ascertaining the views of the Australian Society of Gynaecologic Oncologists (ASGO) about important clinical questions in this field, current treatment preferences, and willingness to participate in trials to address these questions. Members of ASGO received a mailed survey. Thirty-one gyneoncologists participated in this study (79% response fraction). There was considerable support for an RCT (81%; 95% confidence interval [CI], 63-93%) to compare sentinel node biopsy with total groin dissection for women with vulval cancer. This clinical question was also rated as "extremely" or "very" important by 91% (95% CI, 74-98%) of respondents, who also indicated high levels of individual equipoise. Another priority for research involved the use of second-line chemotherapy for women who have rising CA125 titers. This clinical question was rated as extremely or very important by 71% (95% CI, 52-86%), exhibited high levels of individual equipoise, with 74% (95% CI, 55-88%) of respondents willing to participate in an RCT to address this issue. The conduct of surveys of representative groups of clinicians provides useful empirical data to focus clinical research efforts where they are most likely to be successful based on equipoise, feasibility, and clinical interest.
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Affiliation(s)
- J D Harrison
- Surgical Outcomes Research Centre, Sydney South West Area Health Service and the University of Sydney, Missenden Road, NSW 2050, Sydney, Australia.
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Lauritzen P. Response to Richard B. Miller's "Children, Ethics, and Modern Medicine". THE JOURNAL OF RELIGIOUS ETHICS 2006; 34:151-161. [PMID: 17203559 DOI: 10.1111/j.1467-9795.2006.00261.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Evans EL, London AJ. Equipoise and the criteria for reasonable action. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2006; 34:441-50. [PMID: 16789966 DOI: 10.1111/j.1748-720x.2006.00050.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
In her recent article, “Evidence, Belief, and Action: The Failure of Equipoise to Resolve the Ethical Tension in the Randomized Clinical Trial,” Deborah Hellman gives a new twist to an old objection against clinical equipoise. Roughly, clinical equipoise is the requirement that there exist credible uncertainty in the expert medical community regarding the preferred treatment for a particular condition. This uncertainty is widely regarded as a necessary condition for enrolling participants in a clinical trial. The old objection is that clinical equipoise represents an overly permissive, and therefore morally unacceptable, mechanism for resolving the fundamental tension in clinical research between fidelity to the interests of the individual research participant, and fidelity to the statistical and scientific methods that are necessary to produce generalizable data in a reliable manner. Hellman's new twist on this objection utilizes some of the rudimentary architecture of Bayesian statistical theory to argue that clinical equipoise focuses our moral attention on the wrong issue.
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Affiliation(s)
- Emily L Evans
- Department of Philosophy at Georgetown University, USA
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Abstract
A probabilistic explication is offered of equipoise and uncertainty in clinical trials. In order to be useful in the justification of clinical trials, equipoise has to be interpreted in terms of overlapping probability distributions of possible treatment outcomes, rather than point estimates representing expectation values. Uncertainty about treatment outcomes is shown to be a necessary but insufficient condition for the ethical defensibility of clinical trials. Additional requirements are proposed for the nature of that uncertainty. The indecisiveness of our criteria for cautious decision-making under uncertainty creates the leeway that makes clinical trials defensible.
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Affiliation(s)
- Sven Ove Hansson
- Department of Philosophy and the History of Technology, Royal Institute of Technology, Teknikringen 78, 100 44 Stockholm, Sweden.
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Creel AH, Losina E, Mandl LA, Marx RJ, Mahomed NN, Martin SD, Martin TL, Millett PJ, Fossel AH, Katz JN. An assessment of willingness to participate in a randomized trial of arthroscopic knee surgery in patients with osteoarthritis. Contemp Clin Trials 2005; 26:169-78. [PMID: 15837439 DOI: 10.1016/j.cct.2004.12.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2004] [Revised: 12/03/2004] [Accepted: 12/22/2004] [Indexed: 01/09/2023]
Abstract
Identifying barriers to recruitment into a randomized clinical trial can help researchers adjust recruitment strategies to maximize enrollment. To determine barriers to enrollment of patients in trials of knee osteoarthritis treatments, we recruited from three centers patients over age 45 who had both knee osteoarthritis and a meniscal tear. We described a hypothetical randomized trial of arthroscopic partial meniscectomy versus non-operative management and assessed patients' willingness to participate in such a trial. We elicited preferences for treatment along with information on age, sex, education level, race, work status, and pain. We examined the association between these factors and willingness to participate in the trial. Orthopedic surgeons identified 106 eligible osteoarthritis patients, of whom 12 could not be reached, 6 refused and 88 (83%) completed interviews. 63% were female, 55% were college graduates, 23% were non-white and mean age was 60+/-8. The mean WOMAC pain score was 56+/-23. 22% of patients stated that they were definitely willing to participate in the hypothetical trial, and 24% stated they were probably willing. Subjects lacking strong preferences for treatment stated a greater willingness to participate than those with strong preferences (36-14% definitely willing, chi(2) for trend, p=0.005). WOMAC pain score, age, education, work status and race were not associated with willingness to participate. Males were more likely than females to state a willingness to participate (39-11% definitely willing, p=0.005). Since OA affects females disproportionately, a better understanding of barriers to females' participation in trials may enhance future research on treatment of osteoarthritis. Effectively addressing a priori treatment preferences through patient education about the advantages and drawbacks of treatments may increase willingness to participate in trials.
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Affiliation(s)
- Alisha H Creel
- Section of Clinical Sciences, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, USA
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Bower P, King M, Nazareth I, Lampe F, Sibbald B. Patient preferences in randomised controlled trials: conceptual framework and implications for research. Soc Sci Med 2005; 61:685-95. [PMID: 15899326 DOI: 10.1016/j.socscimed.2004.12.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2004] [Accepted: 12/14/2004] [Indexed: 11/27/2022]
Abstract
Patient preferences have recently been highlighted as a potential threat to the validity of randomised controlled trials (RCTs). Although there have been significant methodological and statistical developments in relation to these issues, comparatively little attention has been paid to the development of a conceptual model concerning preferences and their effects on decision-making. This article describes the development of such a model, which was undertaken in parallel with a systematic review of the empirical data concerning preference effects. The model describes the concept of preference in terms of theoretical concepts from the psychological and economics literature, and describes a preliminary model of the development and operation of preferences in the context of RCTs. The paper then examines the implications of the model for informed consent and recruitment procedures. Key issues for future research are also outlined.
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Affiliation(s)
- Peter Bower
- NPCRDC, 5th Floor, Williamson Building, University of Manchester, Manchester M13 9PL, UK.
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Ashcroft RE. Ethics of randomised controlled trials--not yet time to give up on equipoise. Arthritis Res Ther 2004; 6:237-9. [PMID: 15535836 PMCID: PMC1064870 DOI: 10.1186/ar1442] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
In this commentary on Fries and Krishnan's argument that 'design bias' undermines the status of equipoise as the ethical justification for randomised controlled trials, it is argued that their argument is analogous to Bayesian arguments for the use of informative priors in trial design, but that this does not undermine the importance of equipoise. In particular, mismatches between the outcomes of interest to industrial sponsors of research and outcomes of interest to patients and clinicians ensure that in many cases industry-sponsored trials can fail to reflect the reasonable equipoise of working clinicians.
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Fries JF, Krishnan E. Equipoise, design bias, and randomized controlled trials: the elusive ethics of new drug development. Arthritis Res Ther 2004; 6:R250-5. [PMID: 15142271 PMCID: PMC416446 DOI: 10.1186/ar1170] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2004] [Revised: 02/24/2004] [Accepted: 03/03/2004] [Indexed: 11/24/2022] Open
Abstract
The concept of 'equipoise', or the 'uncertainty principle', has been represented as a central ethical principle, and holds that a subject may be enrolled in a randomized controlled trial (RCT) only if there is true uncertainty about which of the trial arms is most likely to benefit the patient. We sought to estimate the frequency with which equipoise conditions were met in industry-sponsored RCTs in rheumatology, to explore the reasons for any deviations from equipoise, to examine the concept of 'design bias', and to consider alternative ethical formulations that might improve subject safety and autonomy. We studied abstracts accepted for the 2001 American College of Rheumatology meetings that reported RCTs, acknowledged industry sponsorship, and had clinical end-points (n = 45), and examined the proportion of studies that favored the registration or marketing of the sponsor's drug. In every trial (45/45) results were favorable to the sponsor, indicating that results could have been predicted in advance solely by knowledge of sponsorship (P < 0.0001). Equipoise clearly was being systematically violated. Publication bias appeared to be an incomplete explanation for this dramatic result; this bias occurs after a study is completed. Rather, we hypothesize that 'design bias', in which extensive preliminary data are used to design studies with a high likelihood of being positive, is the major cause of the asymmetric results. Design 'bias' occurs before the trial is begun and is inconsistent with the equipoise principle. However, design bias increases scientific efficiency, decreases drug development costs, and limits the number of subjects required, probably reducing aggregate risks to participants. Conceptual and ethical issues were found with the equipoise principle, which encourages performance of negative studies; ignores patient values, patient autonomy, and social benefits; is applied at a conceptually inappropriate decision point (after randomization rather than before); and is in conflict with the Belmont, Nuremberg, and other sets of ethical principles, as well as with US Food and Drug Administration procedures. We propose a principle of 'positive expected outcomes', which informs the assessment that a trial is ethical, together with a restatement of the priority of personal autonomy.
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Affiliation(s)
- James F Fries
- Stanford University School of Medicine, Palo Alto, California, USA.
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Eldredge JD. The randomised controlled trial design: unrecognized opportunities for health sciences librarianship. Health Info Libr J 2003; 20 Suppl 1:34-44. [PMID: 12757434 DOI: 10.1046/j.1365-2532.20.s1.7.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE to describe the essential components of the Randomised Controlled Trial (RCT) and its major variations; to describe less conventional applications of the RCT design found in the health sciences literature with potential relevance to health sciences librarianship; to discuss the limited number of RCTs within health sciences librarianship. METHODS narrative review supported to a limited extent with PubMed and Library Literature database searches consistent with specific search parameters. In addition, more systematic methods, including handsearching of specific journals, to identify health sciences librarianship RCTs. RESULTS While many RCTs within the health sciences follow more conventional patterns, some RCTs assume certain unique features. Selected examples illustrate the adaptations of this experimental design to answering questions of possible relevance to health sciences librarians. The author offers several strategies for controlling bias in library and informatics applications of the RCT and acknowledges the potential of the electronic era in providing many opportunities to utilize the blinding aspects of RCTs. RCTs within health sciences librarianship inhabit a limited number of subject domains such as education. This limited scope offers both advantages and disadvantages for making Evidence-Based Librarianship (EBL) a reality. CONCLUSIONS The RCT design offers the potential to answer far more EBL questions than have been addressed by the design to date. Librarians need only extend their horizons through use of the versatile RCT design into new subject domains to facilitate making EBL a reality.
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Affiliation(s)
- Jonathan D Eldredge
- The University of New Mexico, Health Sciences Library and Informatics Center, Albuquerque, NM 87131, USA.
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Mills N, Donovan JL, Smith M, Jacoby A, Neal DE, Hamdy FC. Perceptions of equipoise are crucial to trial participation: a qualitative study of men in the ProtecT study. CONTROLLED CLINICAL TRIALS 2003; 24:272-82. [PMID: 12757993 DOI: 10.1016/s0197-2456(03)00020-5] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Recruitment to trials is known to be difficult. Previous research suggests that a crucial factor may be participants' difficulty with the concept of randomization. This study explored patients' perceptions of randomization and reasons for consent or refusal to participate in the ProtecT study (a randomized trial of surgery, radiotherapy, and monitoring for localized prostate cancer). In-depth interviews were conducted with 21 men diagnosed with localized prostate cancer who were invited to participate in the ProtecT treatment trial. Interviewees were selected purposefully from three U.K. clinical centers to ensure the inclusion of similar proportions of those agreeing or refusing random treatment allocation in each of the treatment groups. Interviews explored men's recall and understanding of chance, comparison, and equipoise, and reasons for consent/refusal of randomization and acceptance/rejection of treatment allocation. Data were analyzed methodically using the techniques of constant comparison. Checking of coding and interpretation was assured by four experienced qualitative researchers. Recall and understanding of the major principles of the randomized design were good and were similar for "chance" and "comparison" between those who consented to and refused randomization. Clinical equipoise, however, caused difficulty. Almost all recalled and understood it, but those who found it acceptable tended to consent to randomization and those who could not accept it tended to refuse to participate. Belief in clinical equipoise was key to participants' consent to randomization. Ensuring patients understand and accept equipoise may thus increase their readiness to consent to participate in trials. A priority for future research is to focus on the provision and presentation of suitable and effective trial information, concentrating in particular on the neglected concept of clinical equipoise.
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Affiliation(s)
- Nicola Mills
- Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, United Kingdom.
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Abstract
Evidence-based medicine (EBM) has achieved cult status in the last 10 years or so. It is an altogether admirable movement in medicine, capable of a great deal of good. Its privileged status, however, has prevented critics from being heard, and there are problems with EBM. Eight features need further discussion if EBM is not to be discredited and superseded. They are its reductionism; its unwitting paternalism; its privileging of restricted kinds of evidence; its dependence on the questionable concept of equipoise; the instability of the 'truths' it produces; its capacity to eliminate individuals in favour of categories; its historical arrogance; and its contempt for the wisdom and integrity of our predecessors. Evidence-based medicine is here to stay; for the moment, at least. It is sufficiently well established to withstand critique. It needs criticism if it is to survive and flourish.
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Affiliation(s)
- Miles Little
- Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, New South Wales, Australia.
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Abstract
RATIONALE, AIMS AND OBJECTIVES Randomized controlled trials (RCTs) have emerged as the most reliable method of assessing the effects of health care interventions in clinical medicine. However, RCTs should be undertaken only if there is substantial uncertainty about which of the trial treatments would benefit a patient most. The purpose of this study is to determine the degree of uncertainty in a research hypothesis before it can empirically be tested in an RCT. METHODS We integrated arguments from three independent lines of research - on ethics, principles of the design and conduct of clinical trials, and medical decision making - to develop a decision model to help solve the dilemma of under which circumstances innovative treatments should be tested in an RCT. RESULTS We showed that RCTs are the preferable option to resolve uncertainties about competing treatment alternatives whenever we desire reliable, undisputed, high-quality evidence with a low likelihood of false-positive or false-negative results. CONCLUSIONS When the expected benefit:risk ratio of a new treatment is small, an RCT is justified to resolve uncertainties over a wide range of prior belief (e.g. 10-90) in the accuracy of the research hypothesis. Randomized controlled trials represent the best means for resolving uncertainties about health care interventions.
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Affiliation(s)
- Benjamin Djulbegovic
- Interdisciplinary Oncology Programme, H. Lee Moffitt Cancer Center and Research Institute at the University of South Florida, Tampa 33612, USA.
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Abstract
Pressures for rapid drug development, especially for treatments that may affect public health significantly, drive a need to reconsider what is necessary to establish the "substantial evidence" of efficacy and safety required for regulatory approval. The concept of substantial evidence of effect can be stated fairly simply in principle, but its application to the evaluation of findings from real clinical drug development programs can be quite complicated and depend on circumstances relating to the population studied and the condition being treated. This paper discusses a number of considerations that arise in attempting to address this issue. These include confirmation of efficacy/safety as opposed to replication of results, the use of surrogates for the clinical outcome, ethical considerations, the use of trials aimed at demonstrating equivalence or noninferiority instead of superiority of a new drug, and the balance between benefits and risks. Recent developments such as the International Conference on Harmonization (ICH) guidelines dealing with statistical principles and choice of control group, and Food and Drug Administration (FDA) guidances interpreting the 1998 Modernization Act identify useful alternative definitions of substantial evidence and also identify when a single study can be enough to demonstrate a clinically important effect. The primary difficulty with the use of noninferiority trials is the need to demonstrate assay sensitivity or validity, i.e., that the trial would have demonstrated the superiority of the active control treatment to placebo had the trial included a placebo group. Failure to demonstrate a significant difference between the presumed active treatments and an inactive control precludes a definitive conclusion of assay validity, but external evidence, e.g., from trials demonstrating the activity of the active control, may yet justify concluding that the trial was assay valid. Issues of interpretation of important unexpected findings are illustrated in the recent experience with the alpha- and beta-blocker carvedilol, where there was a significant reduction in mortality among patients on carvedilol relative to placebo, but a treatment effect could not be demonstrated for the primary outcome. Experience with trials of thrombolytic agents illustrates alternative strategies for demonstrating substantial evidence of effect. Finally, meta-analyses can contribute to the substantial evidence by synthesizing the findings from separate trials to provide a perspective on drug performance in a heterogeneous population of patients that no single trial could provide.
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Tenery R, Rakatansky H, Riddick FA, Goldrich MS, Morse LJ, O'Bannon JM, Ray P, Smalley S, Weiss M, Kao A, Morin K, Maixner A, Seiden S. Surgical "placebo" controls. Ann Surg 2002; 235:303-7. [PMID: 11807373 PMCID: PMC1422430 DOI: 10.1097/00000658-200202000-00021] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To set ethical guidelines on the use of surgical placebo controls in the design of surgical trials. BACKGROUND DATA Ethical concerns recently arose from surgical trials where subjects in the control arm underwent surgical procedures that had the appearance of a therapeutic intervention, but during which the essential therapeutic maneuver was omitted. Although there are ethical guidelines on the use of a placebo in drug trials, little attention has been paid to the use of a surgical placebo control in surgical trials. METHODS The Council on Ethical and Judicial Affairs developed ethical guidelines based on a wide literature search and consultation with experts. RESULTS Surgical placebo controls should be limited to studies of new surgical procedures aimed at treating diseases that are not amenable to other surgical therapies, and are reasonably anticipated to be susceptible to substantial placebo effects. If the standard nonsurgical treatment is efficacious and acceptable to the patient, then it must be offered as part of the study design. CONCLUSIONS Surgical placebo controls should be used only when no other trial design will yield the requisite data and should always be accompanied by a rigorous informed consent process and a careful consideration of the related risks and benefits. The recommended ethical guidelines were adopted as AMA ethics policy and are now incorporated in the AMA's Code of Medical Ethics.
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Affiliation(s)
- Robert Tenery
- Council on Ethical and Judicial Affairs of the American Medical Association, Chicago, Illinois 60610, USA
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Affiliation(s)
- Elizabeth Murray
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, University College London, UK.
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Djulbegovic B. Acknowledgment of uncertainty: a fundamental means to ensure scientific and ethical validity in clinical research. Curr Oncol Rep 2001; 3:389-95. [PMID: 11489238 DOI: 10.1007/s11912-001-0024-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Recognition of the importance of uncertainty in the design of randomized, controlled trials (RCT) has reached the status of a principle. The "uncertainty principle," or less ambiguously, equipoise, holds that a patient should be enrolled in an RCT only if there is substantial uncertainty about which of the trial treatments would benefit the patient most. In fact, the "uncertainty principle" addresses the most important issue of a clinical trial--the choice of an adequate comparative control. Studies in which intervention and control group are believed to be non-equivalent violate the uncertainty principle. Therefore, one would expect that both editors and authors would be particularly careful to include a statement concerning prior beliefs of the investigator(s) about the uncertainty of the treatments that are reported. However, we found no evidence of such a policy in the randomized, controlled trials we examined. We also show that there is a predictable relationship between the uncertainty principle, that is, the moral principle upon which trials are based, and the ultimate outcomes of clinical trials. We postulate that about 50% of innovations are successful, leading to the conclusion that preserving the ethics of clinical research may be the best investment strategy available.
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Affiliation(s)
- B Djulbegovic
- Interdisciplinary Oncology Program, Division of Blood and Bone Marrow Transplantation, H. Lee Moffitt Cancer Center, University of South Florida, 12902 Magnolia Drive, Tampa, FL 33612, USA.
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Webb SA. Are randomized controlled trials ethical in critically ill children? Crit Care Med 2000; 28:1246-8. [PMID: 10809327 DOI: 10.1097/00003246-200004000-00070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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