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Welch LC, Brewer SK, Schleyer T, Daudelin D, Paranal R, Hunt JD, Dozier AM, Perry A, Cabrera AB, Gatto CL. Learning health system benefits: Development and initial validation of a framework. Learn Health Syst 2024; 8:e10380. [PMID: 38249854 PMCID: PMC10797574 DOI: 10.1002/lrh2.10380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/14/2023] [Accepted: 06/22/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction Implementation of research findings in clinical practice often is not realized or only partially achieved, and if so, with a significant delay. Learning health systems (LHSs) hold promise to overcome this problem by embedding clinical research and evidence-based best practices into care delivery, enabling innovation and continuous improvement. Implementing an LHS is a complex process that requires participation and resources of a wide range of stakeholders, including healthcare leaders, clinical providers, patients and families, payers, and researchers. Engaging these stakeholders requires communicating clear, tangible value propositions. Existing models identify broad categories of benefits but do not explicate the full range of benefits or ways they can manifest in different organizations. Methods To develop such a framework, a working group with representatives from six Clinical and Translational Science Award (CTSA) hubs reviewed existing literature on LHS characteristics, models, and goals; solicited expert input; and applied the framework to their local LHS experiences. Results The Framework of LHS Benefits includes six categories of benefits (quality, safety, equity, patient satisfaction, reputation, and value) relevant for a range of stakeholders and defines key concepts within each benefit. Applying the framework to five LHS case examples indicated preliminary face validity across varied LHS approaches and revealed three dimensions in which the framework is relevant: defining goals of individual LHS projects, facilitating collaboration based on shared values, and establishing guiding tenets of an LHS program or mission. Conclusion The framework can be used to communicate the value of an LHS to different stakeholders across varied contexts and purposes, and to identify future organizational priorities. Further validation will contribute to the framework's evolution and support its potential to inform the development of tools to evaluate LHS impact.
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Affiliation(s)
- Lisa C. Welch
- Tufts Clinical and Translational Science InstituteTufts UniversityBostonMassachusettsUSA
| | - Sarah K. Brewer
- Tufts Clinical and Translational Science InstituteTufts UniversityBostonMassachusettsUSA
| | - Titus Schleyer
- Center for Biomedical InformaticsRegenstrief InstituteIndianapolisIndianaUSA
- Indiana Clinical and Translational Sciences InstituteIndiana UniversityIndianapolisIndianaUSA
| | - Denise Daudelin
- Tufts Clinical and Translational Science InstituteTufts UniversityBostonMassachusettsUSA
| | - Rechelle Paranal
- South Carolina Clinical and Translational Research Institute, Medical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Joe D. Hunt
- Indiana Clinical and Translational Sciences InstituteIndiana UniversityIndianapolisIndianaUSA
| | - Ann M. Dozier
- University of Rochester Clinical and Translational Science Institute, University of RochesterRochesterNew YorkUSA
| | - Anna Perry
- Wake Forest Clinical and Translational Science Institute, Wake Forest University School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Alyssa B. Cabrera
- Tufts Clinical and Translational Science InstituteTufts UniversityBostonMassachusettsUSA
| | - Cheryl L. Gatto
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical CenterNashvilleTennesseeUSA
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Somerville M, Cassidy C, Curran JA, Johnson C, Sinclair D, Elliott Rose A. Implementation strategies and outcome measures for advancing learning health systems: a mixed methods systematic review. Health Res Policy Syst 2023; 21:120. [PMID: 38012681 PMCID: PMC10680228 DOI: 10.1186/s12961-023-01071-w] [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: 03/24/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Learning health systems strive to continuously integrate data and evidence into practice to improve patient outcomes and ensure value-based healthcare. While the LHS concept is gaining traction, the operationalization of LHSs is underexplored. OBJECTIVE To identify and synthesize the existing evidence on the implementation and evaluation of advancing learning health systems across international health care settings. METHODS A mixed methods systematic review was conducted. Six databases (CINAHL, Embase, Medline, PAIS, Scopus and Nursing at Allied Health Database) were searched up to July 2022 for terms related to learning health systems, implementation, and evaluation measures. Any study design, health care setting and population were considered for inclusion. No limitations were placed on language or date of publication. Two reviewers independently screened the titles, abstracts, and full texts of identified articles. Data were extracted and synthesized using a convergent integrated approach. Studies were critically appraised using relevant JBI critical appraisal checklists. RESULTS Thirty-five studies were included in the review. Most studies were conducted in the United States (n = 21) and published between 2019 and 2022 (n = 24). Digital data capture was the most common LHS characteristic reported across studies, while patient engagement, aligned governance and a culture of rapid learning and improvement were reported least often. We identified 33 unique strategies for implementing LHSs including: change record systems, conduct local consensus discussions and audit & provide feedback. A triangulation of quantitative and qualitative data revealed three integrated findings related to the implementation of LHSs: (1) The digital infrastructure of LHSs optimizes health service delivery; (2) LHSs have a positive impact on patient care and health outcomes; and (3) LHSs can influence health care providers and the health system. CONCLUSION This paper provides a comprehensive overview of the implementation of LHSs in various healthcare settings. While this review identified key implementation strategies, potential outcome measures, and components of functioning LHSs, further research is needed to better understand the impact of LHSs on patient, provider and population outcomes, and health system costs. Health systems researchers should continue to apply the LHS concept in practice, with a stronger focus on evaluation.
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Affiliation(s)
| | - Christine Cassidy
- Faculty of Health, School of Nursing, Dalhousie University, Halifax, NS, Canada
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Jagsi R, Suresh K, Krenz CD, Jones RD, Griffith KA, Perry L, Hawley ST, Zikmund-Fisher B, Spector-Bagdady K, Platt J, De Vries R, Bradbury AR, Bansal P, Kaime M, Patel M, Schilsky RL, Miller RS, Spence R. Health Data Sharing Perspectives of Patients Receiving Care in CancerLinQ-Participating Oncology Practices. JCO Oncol Pract 2023; 19:626-636. [PMID: 37220315 PMCID: PMC10424907 DOI: 10.1200/op.23.00080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/09/2023] [Indexed: 05/25/2023] Open
Abstract
PURPOSE CancerLinQ seeks to use data sharing technology to improve quality of care, improve health outcomes, and advance evidence-based research. Understanding the experiences and concerns of patients is vital to ensure its trustworthiness and success. METHODS In a survey of 1,200 patients receiving care in four CancerLinQ-participating practices, we evaluated awareness and attitudes regarding participation in data sharing. RESULTS Of 684 surveys received (response rate 57%), 678 confirmed cancer diagnosis and constituted the analytic sample; 54% were female, and 70% were 60 years and older; 84% were White. Half (52%) were aware of the existence of nationwide databases focused on patients with cancer before the survey. A minority (27%) indicated that their doctors or staff had informed them about such databases, 61% of whom indicated that doctors or staff had explained how to opt out of data sharing. Members of racial/ethnic minority groups were less likely to be comfortable with research (88% v 95%; P = .002) or quality improvement uses (91% v 95%; P = .03) of shared data. Most respondents desired to know how their health information was used (70%), especially those of minority race/ethnicity (78% v 67% of non-Hispanic White respondents; P = .01). Under half (45%) felt that electronic health information was sufficiently protected by current law, and most (74%) favored an official body for data governance and oversight with representation of patients (72%) and physicians (94%). Minority race/ethnicity was associated with increased concern about data sharing (odds ratio [OR], 2.92; P < .001). Women were less concerned about data sharing than men (OR, 0.61; P = .001), and higher trust in oncologist was negatively associated with concern (OR, 0.75; P = .03). CONCLUSION Engaging patients and respecting their perspectives is essential as systems like CancerLinQ evolve.
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Korona-Bailey J, Janvrin ML, Juman L, Koehlmoos TP. Voice of the Customer: Factors Impacting Beneficiary Choice of Programs in TRICARE. J Patient Exp 2023; 10:23743735231184762. [PMID: 37528954 PMCID: PMC10388615 DOI: 10.1177/23743735231184762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
Little is known about how a consumer would choose a health plan if cost was not an option such as in the Military Health System. We sought to identify how to recruit TRICARE beneficiaries into new pilot programs challenged by low recruitment. We developed a semistructured interview guide by adapting a framework established by Klinkman to assess factors in choosing a health plan. Using social media platforms, we recruited TRICARE Prime and Select beneficiaries to participate in key informant interviews from October to December 2022. We conducted inductive thematic analysis to determine key areas of concern. We interviewed a total of 20 TRICARE Prime and Select beneficiaries. The majority were women, above age 40, had a master's degree, a sponsor in the US Army and of senior officer rank. Four overarching themes emerged: (I) patient choice; (II) access to care; (III) quality of care; and (IV) cost. This evaluation of TRICARE beneficiaries explores how to motivate high-quality value-based care in a traditionally fee for service system.
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Affiliation(s)
- Jessica Korona-Bailey
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Miranda Lynn Janvrin
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Luke Juman
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Tracey Perez Koehlmoos
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Cumyn A, Ménard JF, Barton A, Dault R, Lévesque F, Ethier JF. Patients and Members of the Public’s Wishes Regarding Transparency in the Context of Secondary Use of Health Data: A Scoping Review (Preprint). J Med Internet Res 2022; 25:e45002. [PMID: 37052967 PMCID: PMC10141314 DOI: 10.2196/45002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/09/2023] [Accepted: 03/03/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Secondary use of health data has reached unequaled potential to improve health systems governance, knowledge, and clinical care. Transparency regarding this secondary use is frequently cited as necessary to address deficits in trust and conditional support and to increase patient awareness. OBJECTIVE We aimed to review the current published literature to identify different stakeholders' perspectives and recommendations on what information patients and members of the public want to learn about the secondary use of health data for research purposes and how and in which situations. METHODS Using PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines, we conducted a scoping review using Medline, CINAHL, PsycINFO, Scopus, Cochrane Library, and PubMed databases to locate a broad range of studies published in English or French until November 2022. We included articles reporting a stakeholder's perspective or recommendations of what information patients and members of the public want to learn about the secondary use of health data for research purposes and how or in which situations. Data were collected and analyzed with an iterative thematic approach using NVivo. RESULTS Overall, 178 articles were included in this scoping review. The type of information can be divided into generic and specific content. Generic content includes information on governance and regulatory frameworks, technical aspects, and scientific aims. Specific content includes updates on the use of one's data, return of results from individual tests, information on global results, information on data sharing, and how to access one's data. Recommendations on how to communicate the information focused on frequency, use of various supports, formats, and wording. Methods for communication generally favored broad approaches such as nationwide publicity campaigns, mainstream and social media for generic content, and mixed approaches for specific content including websites, patient portals, and face-to-face encounters. Content should be tailored to the individual as much as possible with regard to length, avoidance of technical terms, cultural competence, and level of detail. Finally, the review outlined 4 major situations where communication was deemed necessary: before a new use of data, when new test results became available, when global research results were released, and in the advent of a breach in confidentiality. CONCLUSIONS This review highlights how different types of information and approaches to communication efforts may serve as the basis for achieving greater transparency. Governing bodies could use the results: to elaborate or evaluate strategies to educate on the potential benefits; to provide some knowledge and control over data use as a form of reciprocity; and as a condition to engage citizens and build and maintain trust. Future work is needed to assess which strategies achieve the greatest outreach while striking a balance between meeting information needs and use of resources.
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Affiliation(s)
- Annabelle Cumyn
- Département de médecine, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, QC, Canada
- Groupe de recherche interdisciplinaire en informatique de la santé, Faculté des sciences/Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Jean-Frédéric Ménard
- Groupe de recherche interdisciplinaire en informatique de la santé, Faculté des sciences/Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, QC, Canada
- Faculté de droit, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Adrien Barton
- Groupe de recherche interdisciplinaire en informatique de la santé, Faculté des sciences/Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, QC, Canada
- Institut de recherche en informatique de Toulouse, Toulouse, France
| | - Roxanne Dault
- Groupe de recherche interdisciplinaire en informatique de la santé, Faculté des sciences/Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Frédérique Lévesque
- Groupe de recherche interdisciplinaire en informatique de la santé, Faculté des sciences/Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Jean-François Ethier
- Département de médecine, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, QC, Canada
- Groupe de recherche interdisciplinaire en informatique de la santé, Faculté des sciences/Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, QC, Canada
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Lee A, Tham J. Opt-in Vs. Opt-out of Organ Donation in Scotland: Bioethical analysis. New Bioeth 2022; 28:341-349. [PMID: 35802413 DOI: 10.1080/20502877.2022.2095714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
This paper looks at the ethics of opt-in vs. opt-out of organ donation as Scotland has transitioned its systems to promote greater organ availability. We first analyse studies that compare the donation rates in other regions due to such a system switch and find that organ increase is inconclusive and modest at best. This is due to a lack of explicit opt-out choices resulting in greater resistance and family override unless there are infrastructures and greater awareness to support such change. The paper then looks at the difference between informed consent of the opt-in vs. presumed consent in the opt-out approaches. Patient autonomy and dignity are better reflected with informed consent. Eighteen months have passed since the new organ donation policy has come into effect, this paper recommends more research into organ donors' psychological motivations to help governments and the healthcare profession obtain more organs for transplantation.
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Affiliation(s)
| | - Joseph Tham
- Bioethics, Regina Apostolorum Pontifical University, Italy
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7
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McLennan S, Rachut S, Lange J, Fiske A, Heckmann D, Buyx A. Practices and attitudes of Bavarian stakeholders regarding the secondary-use of health data for research purposes during the COVID-19 pandemic: a qualitative interview study (Preprint). J Med Internet Res 2022; 24:e38754. [PMID: 35696598 PMCID: PMC9239567 DOI: 10.2196/38754] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/28/2022] [Accepted: 05/29/2022] [Indexed: 01/14/2023] Open
Abstract
Background The COVID-19 pandemic is a threat to global health and requires collaborative health research efforts across organizations and countries to address it. Although routinely collected digital health data are a valuable source of information for researchers, benefiting from these data requires accessing and sharing the data. Health care organizations focusing on individual risk minimization threaten to undermine COVID-19 research efforts, and it has been argued that there is an ethical obligation to use the European Union’s General Data Protection Regulation (GDPR) scientific research exemption during the COVID-19 pandemic to support collaborative health research. Objective This study aims to explore the practices and attitudes of stakeholders in the German federal state of Bavaria regarding the secondary use of health data for research purposes during the COVID-19 pandemic, with a specific focus on the GDPR scientific research exemption. Methods Individual semistructured qualitative interviews were conducted between December 2020 and January 2021 with a purposive sample of 17 stakeholders from 3 different groups in Bavaria: researchers involved in COVID-19 research (n=5, 29%), data protection officers (n=6, 35%), and research ethics committee representatives (n=6, 35%). The transcripts were analyzed using conventional content analysis. Results Participants identified systemic challenges in conducting collaborative secondary-use health data research in Bavaria; secondary health data research generally only happens when patient consent has been obtained, or the data have been fully anonymized. The GDPR research exemption has not played a significant role during the pandemic and is currently seldom and restrictively used. Participants identified 3 key groups of barriers that led to difficulties: the wider ecosystem at many Bavarian health care organizations, legal uncertainty that leads to risk-adverse approaches, and ethical positions that patient consent ought to be obtained whenever possible to respect patient autonomy. To improve health data research in Bavaria and across Germany, participants wanted greater legal certainty regarding the use of pseudonymized data for research purposes without the patient’s consent. Conclusions The current balance between enabling the positive goals of health data research and avoiding associated data protection risks is heavily skewed toward avoiding risks; so much so that it makes reaching the goals of health data research extremely difficult. This is important, as it is widely recognized that there is an ethical imperative to use health data to improve care. The current approach also creates a problematic conflict with the ambitions of Germany, and the federal state of Bavaria, to be a leader in artificial intelligence. A recent development in the field of German public administration known as norm screening (Normenscreening) could potentially provide a systematic approach to minimize legal barriers. This approach would likely be beneficial to other countries.
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Affiliation(s)
- Stuart McLennan
- Institute of History and Ethics in Medicine, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Sarah Rachut
- TUM Center for Digital Public Services, Department Governance, TUM School of Social Sciences and Technology, Technical University of Munich, Munich, Germany
| | - Johannes Lange
- Institute of History and Ethics in Medicine, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Amelia Fiske
- Institute of History and Ethics in Medicine, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Dirk Heckmann
- TUM Center for Digital Public Services, Department Governance, TUM School of Social Sciences and Technology, Technical University of Munich, Munich, Germany
| | - Alena Buyx
- Institute of History and Ethics in Medicine, TUM School of Medicine, Technical University of Munich, Munich, Germany
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Normand MP, Donohue HE. Research Ethics for Behavior Analysts in Practice. Behav Anal Pract 2022; 16:13-22. [PMID: 37006418 PMCID: PMC10050523 DOI: 10.1007/s40617-022-00698-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 01/10/2023] Open
Abstract
Behavior analysts in practice have an advantage over many others in the helping professions-they have at their disposal a robust science of behavior change informed primarily by single-case experimental research designs. This is advantageous because the research literature is focused on individual behavior change and has direct relevance to behavior analysts who need to change the behavior of individuals in need. Also, the same experimental designs used to advance the basic and applied sciences can be used to evaluate and refine specific procedures as they are put into practice. Thus, behavior-analytic research and practice are often intertwined. However, when behavior analysts in practice conduct research and use their own clients as participants, several important ethical issues need to be considered. Research with human participants is subject to careful ethical oversight, but the ethical guidelines that have been developed are usually described in terms of research conducted by nonpractitioners working in universities or institutions. This article focuses on several areas of special concern when conducting research in practice settings, including dual relationships and conflicts of interest, obtaining informed consent, and using ethical review panels.
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Affiliation(s)
- Matthew P. Normand
- Department of Psychology, University of the Pacific, 3601 Pacific Avenue, Stockton, CA 95211 USA
| | - Hailey E. Donohue
- Department of Psychology, University of the Pacific, 3601 Pacific Avenue, Stockton, CA 95211 USA
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9
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Duenas DM, Shipman KJ, Porter KM, Shuster E, Guerra C, Reyes A, Kauffman TL, Hunter JE, Goddard KAB, Wilfond BS, Kraft SA. Motivations and concerns of patients considering participation in an implementation study of a hereditary cancer risk assessment program in diverse primary care settings. Genet Med 2022; 24:610-621. [PMID: 34906471 PMCID: PMC8939763 DOI: 10.1016/j.gim.2021.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/17/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Understanding the motivations and concerns of patients from diverse populations regarding participation in implementation research provides the needed evidence about how to design and conduct studies for facilitating access to genetics services. Within a hereditary cancer screening study assessing a multifaceted intervention, we examined primary care patients' motivations and concerns about participation. METHODS We surveyed and interviewed study participants after they enrolled, surveyed those who did not complete enrollment, and used descriptive qualitative and quantitative methods to identify motivations and concerns regarding participation. RESULTS Survey respondents' most common motivations included a desire to learn about their future risk (81%), receiving information that may help family (58%), and a desire to advance research (34%). Interviews revealed 3 additional important factors: affordability of testing, convenience of participation, and clinical relationships supporting research decision-making. Survey data of those who declined enrollment showed that the reasons for declining included concerns about privacy (38%), burdens of the research (19%), and their fear of not being able to cope with the genetic information (19%). CONCLUSION Understanding the facilitating factors and concerns that contribute to decisions about research may reveal ways to improve equity in access to care and research that could lead to greater uptake of genomic medicine across diverse primary care patient populations.
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Affiliation(s)
- Devan M Duenas
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA.
| | - Kelly J Shipman
- Palliative Care and Resilience Research Program, Seattle Children's Hospital and Research Institute, Seattle, WA
| | - Kathryn M Porter
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA
| | - Elizabeth Shuster
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Claudia Guerra
- Department of Anthropology, History and Social Medicine, University of California San Francisco, San Francisco, CA
| | - Ana Reyes
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Tia L Kauffman
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | | | - Katrina A B Goddard
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA; Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
| | - Stephanie A Kraft
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA; Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
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Hunt DF, Dunn M, Harrison G, Bailey J. Ethical considerations in quality improvement: key questions and a practical guide. BMJ Open Qual 2021; 10:bmjoq-2021-001497. [PMID: 34404685 PMCID: PMC8372876 DOI: 10.1136/bmjoq-2021-001497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/25/2021] [Indexed: 11/04/2022] Open
Abstract
Quality improvement (QI) provides a rigorous and innovative approach to improving patient's lives in the healthcare system. Still, it can pose challenges in understanding what ethical considerations apply to some projects to minimise the possibility of patient harm or prevent other ethical wrongs and potential staff burden. While many commentaries discuss the extent to which QI ethics should match research ethics, there is minimal literature regarding what QI project teams should do when considering ethics at the planning stage. This paper provides a practical walkthrough of some of the ethical considerations across the breadth of QI projects, starting from some of the key questions when planning a QI project and a guide for the different ethical considerations that may apply.
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Affiliation(s)
- David Francis Hunt
- Department of Experimental Psychology, University of Oxford Medical Sciences Division, Oxford, UK .,Oxford Healthcare Improvement Centre, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Michael Dunn
- The Ethox Centre and Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, Oxfordshire, UK
| | - Guy Harrison
- Department of Spiritual and Pastoral Care, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Jill Bailey
- Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, Oxfordshire, UK.,Coventry and Warwickshire Partnership NHS Trust, Coventry, UK
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Muller SHA, Kalkman S, van Thiel GJMW, Mostert M, van Delden JJM. The social licence for data-intensive health research: towards co-creation, public value and trust. BMC Med Ethics 2021; 22:110. [PMID: 34376204 PMCID: PMC8353823 DOI: 10.1186/s12910-021-00677-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 08/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background The rise of Big Data-driven health research challenges the assumed contribution of medical research to the public good, raising questions about whether the status of such research as a common good should be taken for granted, and how public trust can be preserved. Scandals arising out of sharing data during medical research have pointed out that going beyond the requirements of law may be necessary for sustaining trust in data-intensive health research. We propose building upon the use of a social licence for achieving such ethical governance. Main text We performed a narrative review of the social licence as presented in the biomedical literature. We used a systematic search and selection process, followed by a critical conceptual analysis. The systematic search resulted in nine publications. Our conceptual analysis aims to clarify how societal permission can be granted to health research projects which rely upon the reuse and/or linkage of health data. These activities may be morally demanding. For these types of activities, a moral legitimation, beyond the limits of law, may need to be sought in order to preserve trust. Our analysis indicates that a social licence encourages us to recognise a broad range of stakeholder interests and perspectives in data-intensive health research. This is especially true for patients contributing data. Incorporating such a practice paves the way towards an ethical governance, based upon trust. Public engagement that involves patients from the start is called for to strengthen this social licence. Conclusions There are several merits to using the concept of social licence as a guideline for ethical governance. Firstly, it fits the novel scale of data-related risks; secondly, it focuses attention on trustworthiness; and finally, it offers co-creation as a way forward. Greater trust can be achieved in the governance of data-intensive health research by highlighting strategic dialogue with both patients contributing the data, and the public in general. This should ultimately contribute to a more ethical practice of governance. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00677-5.
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Affiliation(s)
- Sam H A Muller
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CX, Utrecht, The Netherlands.
| | - Shona Kalkman
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CX, Utrecht, The Netherlands
| | - Ghislaine J M W van Thiel
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CX, Utrecht, The Netherlands
| | - Menno Mostert
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CX, Utrecht, The Netherlands
| | - Johannes J M van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, 3584 CX, Utrecht, The Netherlands
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Cumyn A, Barton A, Dault R, Safa N, Cloutier AM, Ethier JF. Meta-consent for the secondary use of health data within a learning health system: a qualitative study of the public's perspective. BMC Med Ethics 2021; 22:81. [PMID: 34187453 PMCID: PMC8240433 DOI: 10.1186/s12910-021-00647-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 06/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The advent of learning healthcare systems (LHSs) raises an important implementation challenge concerning how to request and manage consent to support secondary use of data in learning cycles, particularly research activities. Current consent models in Quebec were not established with the context of LHSs in mind and do not support the agility and transparency required to obtain consent from all involved, especially the citizens. Therefore, a new approach to consent is needed. Previous work identified the meta-consent model as a promising alternative to fulfill the requirements of LHSs, particularly large-scale deployments. We elicited the public's attitude toward the meta-consent model to evaluate if the model could be understood by the citizens and would be deemed acceptable to prepare for its possible implementation in Quebec. METHODS Eight focus groups, with a total of 63 members of the general public from various backgrounds were conducted in Quebec, Canada, in 2019. Explicit attention was given to literacy levels, language spoken at home and rural vs urban settings. We assessed attitudes, concerns and facilitators regarding key components of the meta-consent model: predefined categories to personalized consent requests, a dynamic web-based infrastructure to record meta-consent, and default settings. To analyse the discussions, a thematic content analysis was performed using a qualitative software. RESULTS Our findings showed that participants were supportive of this new approach of consent as it promotes transparency and offers autonomy for the management of their health data. Key facilitators were identified to be considered in the implementation of a meta-consent model in the Quebec LHSs: information and transparency, awareness campaigns, development of educational tools, collaboration of front-line healthcare professionals, default settings deemed acceptable by the society as well as close partnerships with recognized and trusted institutions. CONCLUSIONS This qualitative study reveals the openness of a sample of the Quebec population regarding the meta-consent model for secondary use of health data for research. This first exploratory study conducted with the public is an important step in guiding decision-makers in the next phases of implementing the various strategies to support access and use of health data in Quebec.
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Affiliation(s)
- Annabelle Cumyn
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 2500 Boulevard de l'Université, Sherbrooke, QC, J1K 2R1, Canada
| | - Adrien Barton
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 2500 Boulevard de l'Université, Sherbrooke, QC, J1K 2R1, Canada
- Centre National de la Recherche Scientifique (CNRS) - Institut de Recherche en Informatique de Toulouse (IRIT), 29 rue Jeanne Marvig, 31055, Toulouse, France
| | - Roxanne Dault
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 2500 Boulevard de l'Université, Sherbrooke, QC, J1K 2R1, Canada
| | - Nissrine Safa
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 2500 Boulevard de l'Université, Sherbrooke, QC, J1K 2R1, Canada
| | - Anne-Marie Cloutier
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 2500 Boulevard de l'Université, Sherbrooke, QC, J1K 2R1, Canada
| | - Jean-François Ethier
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, Université de Sherbrooke, 2500 Boulevard de l'Université, Sherbrooke, QC, J1K 2R1, Canada.
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Cumyn A, Dault R, Barton A, Cloutier AM, Ethier JF. Citizens, Research Ethics Committee Members and Researchers' Attitude Toward Information and Consent for the Secondary Use of Health Data: Implications for Research Within Learning Health Systems. J Empir Res Hum Res Ethics 2021; 16:165-178. [PMID: 33710932 PMCID: PMC8236664 DOI: 10.1177/1556264621992214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A survey was conducted to assess citizens, research ethics committee members, and researchers' attitude toward information and consent for the secondary use of health data for research within learning health systems (LHSs). Results show that the reuse of health data for research to advance knowledge and improve care is valued by all parties; consent regarding health data reuse for research has fundamental importance particularly to citizens; and all respondents deemed important the existence of a secure website to support the information and consent processes. This survey was part of a larger project that aims at exploring public perspectives on alternate approaches to the current consent models for health data reuse to take into consideration the unique features of LHSs. The revised model will need to ensure that citizens are given the opportunity to be better informed about upcoming research and have their say, when possible, in the use of their data.
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Affiliation(s)
- Annabelle Cumyn
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,Département de Médecine, Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Roxanne Dault
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,Département de Médecine, Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,Data Access Component, Quebec SPOR Support Unit, 98629Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Adrien Barton
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,27051Centre National de la Recherche Scientifique-Institut de Recherche en Informatique de Toulouse (CNRS-IRIT), Toulouse, Île-de-France, France
| | - Anne-Marie Cloutier
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,Département de Médecine, Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,Data Access Component, Quebec SPOR Support Unit, 98629Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Jean-François Ethier
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,Département de Médecine, Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,Data Access Component, Quebec SPOR Support Unit, 98629Université de Sherbrooke, Sherbrooke, Québec, Canada
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Darsaut TE, Fahed R, Raymond J. Unruptured aneurysms: Why observational studies fall short no matter how "Big" the Data. Neurochirurgie 2021; 67:330-335. [PMID: 33713661 DOI: 10.1016/j.neuchi.2021.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/09/2020] [Accepted: 02/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The best management of unruptured intracranial aneurysms (UIAs) remains unknown, despite multiple observational studies. A randomized trial (RCT) is in order. Yet, a National Institute Neurological Disorders and Stroke workshop has once again proposed to use prospective observational studies (POS) of large databases to address such problems. METHODS We review the historical misconceptions that have been associated with observations of UIAs and their treatments. We critically examine some recent methods that have been proposed to address shortcomings of observational studies. We finally review the ethical principles underlying the use of trial methods in the care of patients. RESULTS Replacing RCTs with POS submits patients to management options that have never been proven beneficial, while making them involuntary research subjects of studies that are inevitably biased. A science of practice cannot be an outsider's examination of the behavior of clinicians incapable of questioning their practice. The thesis we propose is that a science of practice must not only eventually determine what best practice will be; It must engage agents involved in medical practice to transparently reveal the uncertainty that calls for management options to be offered under the guidance of declared and controlled care research, to optimize patient outcomes in spite of the uncertainty. CONCLUSION To use POS rather than RCTs in medical practice is to renege on scientific and ethical principles that characterize modern medicine. Instead, we must learn to integrate care research into our practice to provide optimal medical care in real time.
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Affiliation(s)
- T E Darsaut
- Division of Neurosurgery, Department of Surgery, Mackenzie Health Sciences Center, University of Alberta hospital, 8440 112th Street, Edmonton, T6G 2B7 Alberta, Canada.
| | - R Fahed
- Division of Neurology, Department of Medicine, The Ottawa Hospital-Civic Campus, 1053, Carling Avenue, K1Y 4E9 Ottawa, Ontario, Canada.
| | - J Raymond
- Service of Neuroradiology, Department of Radiology, Centre Hospitalier de l'Université de Montréal, 1000, Saint-Denis, D03.5462B, H2X 0C1 Montreal, Quebec, Canada.
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15
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Jones RD, Krenz C, Griffith KA, Spence R, Bradbury AR, De Vries R, Hawley ST, Zon R, Bolte S, Sadeghi N, Schilsky RL, Jagsi R. Governance of a Learning Health Care System for Oncology: Patient Recommendations. JCO Oncol Pract 2020; 17:e479-e489. [PMID: 33095694 DOI: 10.1200/op.20.00454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The learning health care system (LHS) was designed to enable real-time learning and research by harnessing data generated during patients' clinical encounters. This novel approach begets ethical questions regarding the oversight of users and uses of patient data. Understanding patients' perspectives is vitally important. MATERIALS AND METHODS We conducted democratic deliberation sessions focused on CancerLinQ, a real-world LHS. Experts presented educational content, and then small group discussions were held to elicit viewpoints. The deliberations centered around whether policies should permit or deny certain users and uses of secondary data. De-identified transcripts of the discussions were examined by using thematic analysis. RESULTS Analysis identified two thematic clusters: expectations and concerns, which seemed to inform LHS governance recommendations. Participants expected to benefit from the LHS through the advancement of medical knowledge, which they hoped would improve treatments and the quality of their care. They were concerned that profit-driven users might manipulate the data in ways that could burden or exploit patients, hinder medical decisions, or compromise patient-provider communication. It was recommended that restricted access, user fees, and penalties should be imposed to prevent users, especially for-profit entities, from misusing data. Another suggestion was that patients should be notified of potential ethical issues and included on diverse, unbiased governing boards. CONCLUSION If patients are to trust and support LHS endeavors, their concerns about for-profit users must be addressed. The ethical implementation of such systems should consist of patient representation on governing boards, transparency, and strict oversight of for-profit users.
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Affiliation(s)
| | | | | | | | | | | | - Sarah T Hawley
- University of Michigan, Ann Arbor, MI.,Veterans Administration Ann Arbor Healthcare System, Ann Arbor, MI
| | - Robin Zon
- Michiana Hematology-Oncology, Mishawaka, IN
| | - Sage Bolte
- Inova Schar Cancer Institute, Fairfax, VA
| | - Navid Sadeghi
- University of Texas Southwestern Medical Center, Dallas, TX
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Niranjan SJ, Wallace A, Williams BR, Turkman Y, Williams CP, Bhatia S, Knight S, Rocque GB. Trust but Verify: Exploring the Role of Treatment-Related Information and Patient-Physician Trust in Shared Decision Making Among Patients with Metastatic Breast Cancer. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2020; 35:885-892. [PMID: 31062280 DOI: 10.1007/s13187-019-01538-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
An ideal model for decision making in cancer is shared decision-making (SDM). Primary facilitators in this model are information-seeking about treatment options and patient-physician trust. Previous studies have investigated the role of each of these parameters individually. However, little is known about their convergent role in treatment decision-making. Therefore, we explored perspectives of metastatic breast cancer (MBC) patients and healthcare professionals about the influence of health information-seeking and physician trust in the SDM process. Qualitative interviews with 20 MBC patients and 6 community oncologists, as well as 3 separate focus groups involving lay navigators, nurses, and academic oncologists, were conducted, recorded, and transcribed. Qualitative data analysis employed a content analysis approach, which included a constant comparative method to generate themes from the transcribed textual data. Five emergent themes were identified (1) physicians considered themselves as the patients' primary source of treatment information; (2) patients trusted their physician's treatment recommendations; (3) patients varied in their approach to seeking further health information regarding the discussed treatment options (e.g., internet websites, family and friends, support groups); (4) other healthcare professionals were cognizant of their fundamental role in facilitating further information-seeking; and (5) patient and physician discordant perspectives on shared decision making were present. Patient procurement of treatment information and the capacity to use it effectively in conjunction with patient trust in physicians play an important role in the shared decision-making process.
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Affiliation(s)
- Soumya J Niranjan
- University of Alabama at Birmingham, 1720 2nd Avenue South, 540A, Birmingham, AL, 35294-1212, USA.
| | - Audrey Wallace
- University of Alabama at Birmingham, 1720 2nd Avenue South, 540A, Birmingham, AL, 35294-1212, USA
| | - Beverly R Williams
- University of Alabama at Birmingham, 1720 2nd Avenue South, 540A, Birmingham, AL, 35294-1212, USA
| | - Yasemin Turkman
- University of Alabama at Birmingham, 1720 2nd Avenue South, 540A, Birmingham, AL, 35294-1212, USA
| | - Courtney P Williams
- University of Alabama at Birmingham, 1720 2nd Avenue South, 540A, Birmingham, AL, 35294-1212, USA
| | - Smita Bhatia
- University of Alabama at Birmingham, 1720 2nd Avenue South, 540A, Birmingham, AL, 35294-1212, USA
| | - Sara Knight
- University of Utah, Salt Lake City, UT, 84112, USA
| | - Gabrielle B Rocque
- University of Alabama at Birmingham, 1720 2nd Avenue South, 540A, Birmingham, AL, 35294-1212, USA
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Fahed R, Darsaut TE, Farzin B, Chagnon M, Raymond J. Measuring clinical uncertainty and equipoise by applying the agreement study methodology to patient management decisions. BMC Med Res Methodol 2020; 20:214. [PMID: 32842953 PMCID: PMC7448326 DOI: 10.1186/s12874-020-01095-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 08/03/2020] [Indexed: 11/10/2022] Open
Abstract
Background Clinical uncertainty and equipoise are vague notions that play important roles in contemporary problems of medical care and research, including the design and conduct of pragmatic trials. Our goal was to show how the reliability study methods normally used to assess diagnostic tests can be applied to particular management decisions to measure the degree of uncertainty and equipoise regarding the use of rival management options. Methods We first use thrombectomy in acute stroke as an illustrative example of the method we propose. We then review, item by item, how the various design elements of diagnostic reliability studies can be modified in order to measure clinical uncertainty. Results The thrombectomy example shows sufficient disagreement and uncertainty to warrant the conduct of additional randomized trials. The general method we propose is that a sufficient number of diverse individual cases sharing a similar clinical problem and covering a wide spectrum of clinical presentations be assembled into a portfolio that is submitted to a variety of clinicians who routinely manage patients with the clinical problem. Discussion Clinicians are asked to independently choose one of the predefined management options, which are selected from those that would be compared within a randomized trial that would address the clinical dilemma. Intra-rater agreement can be assessed at a later time with a second evaluation. Various professional judgments concerning individual patients can then be compared and analyzed using kappa statistics or similar methods. Interpretation of results can be facilitated by providing examples or by translating the results into clinically meaningful summary sentences. Conclusions Measuring the uncertainty regarding management options for clinical problems may reveal substantial disagreement, provide an empirical foundation for the notion of equipoise, and inform or facilitate the design/conduct of clinical trials to address the clinical dilemma.
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Affiliation(s)
- Robert Fahed
- Division of Neurology, The Ottawa Hospital, Civic Campus, 1053 Carling Ave, Ottawa, Ontario, K1Y 4E9, Canada
| | - Tim E Darsaut
- Mackenzie Health Sciences Centre, Department of Surgery, Division of Neurosurgery, University of Alberta Hospital, 8440 - 112 Street, Edmonton, Alberta, T6G 2B7, Canada
| | - Behzad Farzin
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier Universitaire de Montréal - CHUM, 1000 Saint-Denis street, room D03-5462B, Montreal, QC, H2X 0C1, Canada
| | - Miguel Chagnon
- Department of Mathematics and Statistic, Pavillion André-Aisenstadt, Université de Montréal, PO Box 6218, succursale Centre-ville, Montreal, Quebec, H3C 3J7, Canada
| | - Jean Raymond
- Department of Radiology, Service of Interventional Neuroradiology, Centre Hospitalier Universitaire de Montréal - CHUM, 1000 Saint-Denis street, room D03-5462B, Montreal, QC, H2X 0C1, Canada.
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Kraft SA, Duenas DM, Lewis H, Shah SK. Bridging the Researcher-Participant Gap: A Research Agenda to Build Effective Research Relationships. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:31-33. [PMID: 32364474 PMCID: PMC7241299 DOI: 10.1080/15265161.2020.1745936] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Stephanie A Kraft
- Seattle Children's Hospital and Research Institute
- University of Washington School of Medicine
| | | | - Hannah Lewis
- Seattle Children's Hospital and Research Institute
| | - Seema K Shah
- Ann and Robert H. Lurie Children's Hospital of Chicago
- Northwestern University Feinberg School of Medicine
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Jones RD, Krenz C, Gornick M, Griffith KA, Spence R, Bradbury AR, De Vries R, Hawley ST, Hayward RA, Zon R, Bolte S, Sadeghi N, Schilsky RL, Jagsi R. Patient Preferences Regarding Informed Consent Models for Participation in a Learning Health Care System for Oncology. JCO Oncol Pract 2020; 16:e977-e990. [PMID: 32352881 DOI: 10.1200/jop.19.00300] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE The expansion of learning health care systems (LHSs) promises to bolster research and quality improvement endeavors. Stewards of patient data have a duty to respect the preferences of the patients from whom, and for whom, these data are being collected and consolidated. METHODS We conducted democratic deliberations with a diverse sample of 217 patients treated at 4 sites to assess views about LHSs, using the example of CancerLinQ, a real-world LHS, to stimulate discussion. In small group discussions, participants deliberated about different policies for how to provide information and to seek consent regarding the inclusion of patient data. These discussions were recorded, transcribed, and de-identified for thematic analysis. RESULTS Of participants, 67% were female, 61% were non-Hispanic Whites, and the mean age was 60 years. Patients' opinions about sharing their data illuminated 2 spectra: trust/distrust and individualism/collectivism. Positions on these spectra influenced the weight placed on 3 priorities: promoting societal altruism, ensuring respect for persons, and protecting themselves. In turn, consideration of these priorities seemed to inform preferences regarding patient choices and system transparency. Most advocated for a policy whereby patients would receive notification and have the opportunity to opt out of including their medical records in the LHS. Participants reasoned that such a policy would balance personal protections and societal welfare. CONCLUSION System transparency and patient choice are vital if patients are to feel respected and to trust LHS endeavors. Those responsible for LHS implementation should ensure that all patients receive an explanation of their options, together with standardized, understandable, comprehensive materials.
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Affiliation(s)
| | | | | | | | | | | | | | - Sarah T Hawley
- University of Michigan, Ann Arbor, MI.,VA Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - Robin Zon
- Michiana Hematology-Oncology, PC, Mishawaka, IN
| | - Sage Bolte
- Inova Schar Cancer Institute, Fairfax, VA
| | - Navid Sadeghi
- University of Texas Southwestern Medical Center, Dallas, TX
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Cumyn A, Barton A, Dault R, Cloutier A, Jalbert R, Ethier J. Informed consent within a learning health system: A scoping review. Learn Health Syst 2020; 4:e10206. [PMID: 32313834 PMCID: PMC7156861 DOI: 10.1002/lrh2.10206] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 09/18/2019] [Accepted: 10/08/2019] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION A major consideration for the implementation of a learning health system (LHS) is consent from participants to the use of their data for research purposes. The main objective of this paper was to identify in the literature which types of consent have been proposed for participation in research observational activities in a LHS. We were particularly interested in understanding which approaches were seen as most feasible and acceptable and in which context, in order to inform the development of a Quebec-based LHS. METHODS Using a scoping review methodology, we searched scientific and legal databases as well as the gray literature using specific terms. Full-text articles were reviewed independently by two authors on the basis of the following concepts: (a) LHS and (b) approach to consent. The selected papers were imported in NVivo software for analysis in the light of a conceptual framework that distinguishes various, largely independent dimensions of consent. RESULTS A total of 93 publications were analysed for this review. Several studies reach opposing conclusions concerning the best approach to consent within a LHS. However, in the light of the conceptual framework we developed, we found that many of these results are distorted by the conflation between various characteristics of consent. Thus, when these characteristics are distinguished, the results mainly suggest the prime importance of the communication process, by contrast to the scope of consent or the kind of action required by participants (opt-in/opt-out). We identified two models of consent that were especially relevant for our purpose: metaconsent and dynamic consent. CONCLUSIONS Our review shows the importance of distinguishing carefully the various features of the consent process. It also suggests that the metaconsent model is a valuable model within a LHS, as it addresses many of the issues raised with regards to feasibility and acceptability. We propose to complement this model by adding the modalities of the information process to the dimensions relevant in the metaconsent process.
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Affiliation(s)
- Annabelle Cumyn
- Département de médecine, Faculté de médecine et des sciences de la santéUniversité de SherbrookeQuebecCanada
- Groupe de recherche interdisciplinaire en informatique de la santé (GRIIS), Faculté de médecine et des sciences de la santé/Faculté des sciencesUniversité de SherbrookeQuebecCanada
| | - Adrien Barton
- Groupe de recherche interdisciplinaire en informatique de la santé (GRIIS), Faculté de médecine et des sciences de la santé/Faculté des sciencesUniversité de SherbrookeQuebecCanada
- Centre national de la recherche scientifique ‐ Institut de recherche en informatique de Toulouse (CNRS‐IRIT)ToulouseFrance
| | - Roxanne Dault
- Groupe de recherche interdisciplinaire en informatique de la santé (GRIIS), Faculté de médecine et des sciences de la santé/Faculté des sciencesUniversité de SherbrookeQuebecCanada
| | - Anne‐Marie Cloutier
- Groupe de recherche interdisciplinaire en informatique de la santé (GRIIS), Faculté de médecine et des sciences de la santé/Faculté des sciencesUniversité de SherbrookeQuebecCanada
| | - Rosalie Jalbert
- Groupe de recherche interdisciplinaire en informatique de la santé (GRIIS), Faculté de médecine et des sciences de la santé/Faculté des sciencesUniversité de SherbrookeQuebecCanada
| | - Jean‐François Ethier
- Département de médecine, Faculté de médecine et des sciences de la santéUniversité de SherbrookeQuebecCanada
- Groupe de recherche interdisciplinaire en informatique de la santé (GRIIS), Faculté de médecine et des sciences de la santé/Faculté des sciencesUniversité de SherbrookeQuebecCanada
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Platt JE, Raj M, Wienroth M. An Analysis of the Learning Health System in Its First Decade in Practice: Scoping Review. J Med Internet Res 2020; 22:e17026. [PMID: 32191214 PMCID: PMC7118548 DOI: 10.2196/17026] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/30/2019] [Accepted: 12/31/2019] [Indexed: 12/20/2022] Open
Abstract
Background In the past decade, Lynn Etheredge presented a vision for the Learning Health System (LHS) as an opportunity for increasing the value of health care via rapid learning from data and immediate translation to practice and policy. An LHS is defined in the literature as a system that seeks to continuously generate and apply evidence, innovation, quality, and value in health care. Objective This review aimed to examine themes in the literature and rhetoric on the LHS in the past decade to understand efforts to realize the LHS in practice and to identify gaps and opportunities to continue to take the LHS forward. Methods We conducted a thematic analysis in 2018 to analyze progress and opportunities over time as compared with the initial Knowledge Gaps and Uncertainties proposed in 2007. Results We found that the literature on the LHS has increased over the past decade, with most articles focused on theory and implementation; articles have been increasingly concerned with policy. Conclusions There is a need for attention to understanding the ethical and social implications of the LHS and for exploring opportunities to ensure that these implications are salient in implementation, practice, and policy efforts.
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Affiliation(s)
- Jodyn E Platt
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Minakshi Raj
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, United States
| | - Matthias Wienroth
- School of Geography, Politics & Sociology, Newcastle University, Newcastle upon Tyne, United Kingdom
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Raymond J, Darsaut TE, Roy D. Care and research concepts should be revised to practice outcome-based medical care. J Clin Epidemiol 2019; 116:155-160. [DOI: 10.1016/j.jclinepi.2019.05.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 04/01/2019] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
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Broekstra R, Aris-Meijer J, Maeckelberghe E, Stolk R, Otten S. Trust in Centralized Large-Scale Data Repository: A Qualitative Analysis. J Empir Res Hum Res Ethics 2019; 15:365-378. [PMID: 31738093 PMCID: PMC7488827 DOI: 10.1177/1556264619888365] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Exponential increases in digital data and calls for participation in human research raise questions about when and why individuals voluntarily provide personal data. We conducted 36 in-depth interviews with ex-participants, participants, and nonparticipants in a biobank to identify key factors influencing trust in centralized large-scale data repository for human research. Our findings indicated that trust depends strongly on whether such data repository benefits the public, the interests of data collectors, the characteristics of the collected data, and application of informed consent for retaining control over personal data. Concerns about the aims and range of data repository appeared to influence withdrawal of participation. Our findings underscore ethical and practical issues relating to data collection and consent procedures in human research.
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Affiliation(s)
| | | | | | - Ronald Stolk
- University Medical Center Groningen, the Netherlands
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Jagsi R, Griffith KA, Jones RD, Krenz C, Gornick M, Spence R, De Vries R, Hawley ST, Zon R, Bolte S, Sadeghi N, Schilsky RL, Bradbury AR. Effect of Public Deliberation on Patient Attitudes Regarding Consent and Data Use in a Learning Health Care System for Oncology. J Clin Oncol 2019; 37:3203-3211. [PMID: 31577472 DOI: 10.1200/jco.19.01693] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE We sought to generate informed and considered opinions regarding acceptable secondary uses of deidentified health information and consent models for oncology learning health care systems. METHODS Day-long democratic deliberation sessions included 217 patients with cancer at four geographically and sociodemographically diverse sites. Patients completed three surveys (at baseline, immediately after deliberation, and 1-month follow-up). RESULTS Participants were 67.3% female, 21.7% black, and 6.0% Hispanic. The most notable changes in perceptions after deliberation related to use of deidentified medical-record data by insurance companies. After discussion, 72.3% of participants felt comfortable if the purpose was to make sure patients receive recommended care (v 79.5% at baseline; P = .03); 24.9% felt comfortable if the purpose was to determine eligibility for coverage or reimbursement (v 50.9% at baseline; P < .001). The most notable change about secondary research use related to believing it was important that doctors ask patients at least once whether researchers can use deidentified medical-records data for future research. The proportion endorsing high importance decreased from baseline (82.2%) to 68.7% immediately after discussion (P < .001), and remained decreased at 73.1% (P = .01) at follow-up. At follow-up, non-Hispanic whites were more likely to consider it highly important to be able to conduct medical research with deidentified electronic health records (96.8% v 87.7%; P = .01) and less likely to consider it highly important for doctors to get a patient's permission each time deidentified medical record information is used for research (23.2% v 51.6%; P < .001). CONCLUSION This research confirms that most patients wish to be asked before deidentified medical records are used for research. Policies designed to realize the potential benefits of learning health care systems can, and should be, grounded in informed and considered public opinion.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Robin Zon
- Michiana Hematology-Oncology PC, Mishawaka, IN
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McLachlan S, Dube K, Johnson O, Buchanan D, Potts HW, Gallagher T, Fenton N. A framework for analysing learning health systems: Are we removing the most impactful barriers? Learn Health Syst 2019; 3:e10189. [PMID: 31641685 PMCID: PMC6802533 DOI: 10.1002/lrh2.10189] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 02/01/2019] [Accepted: 03/05/2019] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Learning health systems (LHS) are one of the major computing advances in health care. However, no prior research has systematically analysed barriers and facilitators for LHS. This paper presents an investigation into the barriers, benefits, and facilitating factors for LHS in order to create a basis for their successful implementation and adoption. METHODS First, the ITPOSMO-BBF framework was developed based on the established ITPOSMO (information, technology, processes, objectives, staffing, management, and other factors) framework, extending it for analysing barriers, benefits, and facilitators. Second, the new framework was applied to LHS. RESULTS We found that LHS shares similar barriers and facilitators with electronic health records (EHR); in particular, most facilitator effort in implementing EHR and LHS goes towards barriers categorised as human factors, even though they were seen to carry fewer benefits. Barriers whose resolution would bring significant benefits in safety, quality, and health outcomes remain.LHS envisage constant generation of new clinical knowledge and practice based on the central role of collections of EHR. Once LHS are constructed and operational, they trigger new data streams into the EHR. So LHS and EHR have a symbiotic relationship. The implementation and adoption of EHRs have proved and continues to prove challenging, and there are many lessons for LHS arising from these challenges. CONCLUSIONS Successful adoption of LHS should take account of the framework proposed in this paper, especially with respect to its focus on removing barriers that have the most impact.
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Affiliation(s)
- Scott McLachlan
- Electrical Engineering and Computer ScienceQueen Mary University of LondonLondonUK
| | - Kudakwashe Dube
- Fundamental SciencesMassey UniversityPalmerston NorthNew Zealand
| | | | - Derek Buchanan
- Fundamental SciencesMassey UniversityPalmerston NorthNew Zealand
| | - Henry W.W. Potts
- Institute of Health InformaticsUniversity College LondonLondonUK
| | | | - Norman Fenton
- Electrical Engineering and Computer ScienceQueen Mary University of LondonLondonUK
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Alami H, Gagnon MP, Fortin JP. [Organizational and systemic conditions of citizen-patient involvement in the development of telehealth in Quebec]. SANTE PUBLIQUE 2019; Vol. 31:125-135. [PMID: 31210508 DOI: 10.3917/spub.191.0125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES Involving citizens-patients in decisions regarding telehealth services could allow a better match between the services offered and the needs and contexts of individuals and communities. This study aims to explore the organizational and systemic conditions that can influence citizen-patient involvement in the development of telehealth in Quebec. METHODS A qualitative study based on semi-structured interviews with 29 key informants was conducted. A deductive-inductive thematic analysis was performed based on an integrative framework derived from diffusion of innovation theories. RESULTS Citizen-patient involvement in the development of telehealth remains dependent on many organizational and systemic conditions. At the organizational level, it could affect the dynamics, process, cultures, rules and operations in organizations; hence the needs for adequate human and material resources as well as the availability of support for change. At the systemic level, the ideology, the sociopolitical context and the decisions in favor (or not) of a citizen appropriation of the decision-making are central. Concerns about scientific evidence, training, as well as the roles of professional federations, and citizen-patient groups have also emerged. Organizational and systemic levels are interdependent. CONCLUSION The organizational and systemic contexts may explain part of the contrast between the discourse in favor of citizen-patient involvement in telehealth decision-making and the reality observed in Quebec. This study provides a basis for analyzing citizen-patient involvement in services development from the perspective of organizational and systemic changes.
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Overcoming knowledge barriers to health care through continuous learning. JOURNAL OF KNOWLEDGE MANAGEMENT 2019. [DOI: 10.1108/jkm-10-2018-0636] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe purpose of this study is to explore the role of continuous learning and the mitigation or elimination of knowledge barriers affecting information technology (IT) assimilation in the health-care sector. Most of the problems with IT assimilations stem from a poor understanding of the nature of suitable information, the lack of trust, cultural differences, the lack of appropriate training and hierarchical bureaucratic structures and procedures. To overcome these barriers, this study provides evidence that a continuous learning process can play a part in overcoming some of the obstacles to the assimilation of IT.Design/methodology/approachThis study investigates how a continuous learning environment can counteract the presence of knowledge barriers, and, along with such an environment, can, in turn, facilitate IT assimilation. The study uses ADANCO 2.0.1 Professional for Windows and involves the collection and analysis of data provided by 210 health-care end users.FindingsThe study provides evidence in support of the proposition that continuous learning may facilitate the assimilation of IT by health-care end users through the mitigation of knowledge barriers (e.g. lack of trust or resistance to change). The mitigation of these barriers requires the gathering and utilization of new knowledge and knowledge structures. The results support the hypothesis that one way in which this can be achieved is through continuous learning (i.e. through assessing the situation, consulting experts, seeking feedback and tracking progress).Research limitations/implicationsA limitation of the study is the relatively simple statistical method that has been used for the analysis. However, the results provided here will serve as a preliminary basis for more sophisticated analysis which is currently underway.Practical implicationsThe study provides useful insights into ways of using continuous learning to facilitate IT assimilation by end users in the health-care domain. This can be of use to hospitals seeking to implement end user IT technologies and, in particular, telemedicine technologies. It can also be used to develop awareness of knowledge barriers and possible approaches to mitigate the effects of such barriers. Such an awareness can assist hospital staff in finding creative solutions for using technology tools. This potentially augments the ability of hospital staff to work with patients and carers, encouraging them to take initiative (make choices and solve problems relevant to them). This, in turn, allows hospitals to avoid negative and thus de-motivating experiences involving themselves and their end users (patients) and improving IT assimilation. This is liable to lead to improved morale and improved assimilation of IT by end users (patients).Social implicationsAs ICT systems and services should entail participation of a wide range of users, developers and stakeholders, including medical doctors, nurses, social workers, patients and programmers and interaction designers, the study provides useful social implication for health management and people well-being.Originality/valueThe paper contributes to a better understanding of the nature and impacts of continuous learning. Although previous studies in the field of knowledge management have shown that knowledge management procedures and routines can provide support to IT assimilation, few studies, if any, have explored the relationship between continuous learning and IT assimilation with particular emphasis on knowledge barriers in the health-care domain.
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Wilfond BS, Porter KM. Justifying Investigator/Clinician Consent When The Physician-Patient Relationship Can Support Better Research Decision-Making. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:26-28. [PMID: 31544673 PMCID: PMC10027386 DOI: 10.1080/15265161.2019.1574496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute and
- University of Washington School of Medicine
| | - Kathryn M Porter
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute and
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Morain SR, Joffe S, Largent EA. When Is It Ethical for Physician-Investigators to Seek Consent From Their Own Patients? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:11-18. [PMID: 30994425 DOI: 10.1080/15265161.2019.1572811] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Classic statements of research ethics advise against permitting physician-investigators to obtain consent for research participation from patients with whom they have preexisting treatment relationships. Reluctance about "dual-role" consent reflects the view that distinct normative commitments govern physician-patient and investigator-participant relationships, and that blurring the research-care boundary could lead to ethical transgressions. However, several features of contemporary research demand reconsideration of the ethics of dual-role consent. Here, we examine three arguments advanced against dual-role consent: that it creates role conflict for the physician-investigator; that it can compromise the voluntariness of the patient-participant's consent; and that it promotes therapeutic misconceptions. Although these concerns have merit in some circumstances, they are not dispositive in all cases. Rather, their force-and the ethical acceptability of dual-role consent-varies with features of the particular study. As research participation more closely approximates usual care, it becomes increasingly acceptable, or even preferable, for physicians to seek consent for research from their own patients. It is time for a more nuanced approach to dual-role consent.
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Affiliation(s)
| | - Steven Joffe
- b University of Pennsylvania Perelman School of Medicine; Children's Hospital of Philadelphia
| | - Emily A Largent
- c University of Pennsylvania Perelman School of Medicine; Leonard Davis Institute of Health Economics
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Trends in Use of Electronic Health Records in Pediatric Office Settings. J Pediatr 2019; 206:164-171.e2. [PMID: 30527749 DOI: 10.1016/j.jpeds.2018.10.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 10/03/2018] [Accepted: 10/23/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To determine the prevalence and functionalities of electronic health records (EHRs) and pediatricians' perceptions of EHRs. STUDY DESIGN An 8-page self-administered questionnaire sent to 1619 randomly selected nonretired US American Academy of Pediatrics members in 2016 was completed by 709 (43.8%). Responses were compared with surveys in 2009 and 2012. RESULTS The percent of pediatricians who were using EHRs increased from 58% in 2009 and 79% in 2012 to 94% in 2016. Those with fully functional EHRs, including pediatric functionality, more than doubled from 8.2% in 2012 to 16.9% in 2016 (P = .01). Fully functional EHRs lacking pediatric functionality increased slightly from 7.8% to 11.1% (P = .3), and the percentage of pediatricians with basic EHRs remained stable (30.4% to 31.0%; P < .3). The percentage of pediatricians who lacked basic EHR functionality or who reported no EHR decreased (from 53.6% to 41.0%; P < .001). On average, pediatricians spent 3.4 hours per day documenting care. CONCLUSIONS Although the adoption of EHRs has increased, >80% of pediatricians are working with EHRs that lack optimal functionality and 41% of pediatricians are not using EHRs with even basic functionality. EHRs lacking pediatric functionality impact the health of children through increased medical errors, missed diagnoses, lack of adherence to guidelines, and reduced availability of child-specific information. The pediatric certification outlined in the 21st Century Cures Act may result in improved EHR products for pediatricians.
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Mbuthia D, Molyneux S, Njue M, Mwalukore S, Marsh V. Kenyan health stakeholder views on individual consent, general notification and governance processes for the re-use of hospital inpatient data to support learning on healthcare systems. BMC Med Ethics 2019; 20:3. [PMID: 30621693 PMCID: PMC6325859 DOI: 10.1186/s12910-018-0343-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 12/26/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Increasing adoption of electronic health records in hospitals provides new opportunities for patient data to support public health advances. Such learning healthcare models have generated ethical debate in high-income countries, including on the role of patient and public consent and engagement. Increasing use of electronic health records in low-middle income countries offers important potential to fast-track healthcare improvements in these settings, where a disproportionate burden of global morbidity occurs. Core ethical issues have been raised around the role and form of information sharing processes for learning healthcare systems, including individual consent and individual and public general notification processes, but little research has focused on this perspective in low-middle income countries. METHODS We conducted a qualitative study on the role of information sharing and governance processes for inpatient data re-use, using in-depth interviews with 34 health stakeholders at two public hospitals on the Kenyan coast, including health managers, providers and researchers. Data were collected between March and July 2016 and analysed using a framework approach, with Nvivo 10 software to support data management. RESULTS Most forms of clinical data re-use were seen as an important public health good. Individual consent and general notification processes were often argued as important, but contingent on interrelated influences of the type of data, use and secondary user. Underlying concerns were linked to issues of patient privacy and autonomy; perceived risks to trust in health systems; and fairness in how data would be used, particularly for non-public sector re-users. Support for engagement often turned on the anticipated outcomes of information-sharing processes, as building or undermining trust in healthcare systems. CONCLUSIONS As reported in high income countries, learning healthcare systems in low-middle counties may generate a core ethical tension between supporting a public good and respecting patient autonomy and privacy, with the maintenance of public trust acting as a core requirement. While more evidence is needed on patient and public perspectives on learning healthcare activities, greater collaboration between public health and research governance systems is likely to support the development of efficient and locally responsive learning healthcare activities in LMICs.
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Affiliation(s)
- Daniel Mbuthia
- Ujamaa Africa, Kenya, 5th Floor, Landmark Plaza, Kamunde Rd, Nairobi, Kenya
| | - Sassy Molyneux
- KEMRI Wellcome Trust Research Programme, Kilifi, 80108 Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, South Parks Road, Oxford University, Oxford, OX1 3SY UK
| | - Maureen Njue
- Institute for Tropical Medicine, Kronenburgstraat 43, 2000 Antwerpen, Belgium
| | - Salim Mwalukore
- KEMRI Wellcome Trust Research Programme, Kilifi, 80108 Kenya
| | - Vicki Marsh
- KEMRI Wellcome Trust Research Programme, Kilifi, 80108 Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, South Parks Road, Oxford University, Oxford, OX1 3SY UK
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Gentry KR, Arnup SJ, Disma N, Dorris L, de Graaff JC, Hunyady A, Morton NS, Withington DE, McCann ME, Davidson AJ, Lynn AM. Enrollment challenges in multicenter, international studies: The example of the GAS trial. Paediatr Anaesth 2019; 29:51-58. [PMID: 30375133 DOI: 10.1111/pan.13522] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 09/17/2018] [Accepted: 09/22/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Randomized trials are important for generating high-quality evidence, but are perceived as difficult to perform in the pediatric population. Thus far there has been poor characterization of the barriers to conducting trials involving children, and the variation in these barriers between countries remains undescribed. The General Anesthesia compared to Spinal anesthesia (GAS) trial, conducted in seven countries between 2007 and 2013, provides an opportunity to explore these issues. METHODS We undertook a descriptive analysis to evaluate the reasons for variation in enrollment between countries in the GAS trial, looking specifically at the number of potential subjects screened, and the subsequent application of four exclusion criteria that were applied in a hierarchical order. RESULTS A total of 4023 patients were screened by 28 centers in seven countries. Australia and the USA screened the most subjects, accounting for 84% of all potential trial participants. The percentage of subjects eliminated from the screened pool by each exclusion criterion varied between countries. Exclusion due to a predefined condition (H1) eliminated only 5% of potential subjects in Italy and the UK, but 37% in Canada. Exclusions due to a contraindication or a physician's refusal most impacted enrollment in Australia and the USA. The patient being "too large for spinal anesthesia" was the most commonly cited by anesthetists who refused to enroll a patient (64% of anesthetist refusals). The majority of surgeon refusals came from the USA, where surgeons preferred the patient to receive a general anesthetic. The percentage of approached parents refusing to consent ranged from a low of 3% in Italy to a high of 70% in the USA and Netherlands. The most frequently cited reason for parent refusal in all countries was a preference for general anesthesia (median: 43%, range: 32%-67%). However, a sizeable proportion of parents in all countries had a contrasting preference for spinal anesthesia (median: 25%, range: 13%-31%), and 23% of U.S. parents expressed concern about randomization. CONCLUSION The GAS trial highlights enrollment challenges that can occur when conducting multicenter, international, pediatric studies. Investigators planning future trials should be aware of potential differences in screening processes across countries, and that exclusions by anesthetists and surgeons may vary in reason, in frequency, and by country. Furthermore, investigators should be aware that the U.S. centers encountered particularly high surgeon and parental refusal rates and that U.S. parents were uniquely concerned about randomization. Planning trials that address these difficulties should increase the likelihood of successfully recruiting subjects in pediatric trials.
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Affiliation(s)
- Katherine R Gentry
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Sarah J Arnup
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Nicola Disma
- Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Liam Dorris
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, UK
| | - Jurgen C de Graaff
- Department of Anaesthesia, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Anesthesia, Erasmus MC Sophia's Children Hospital Rotterdam, Rotterdam, The Netherlands
| | - Agnes Hunyady
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Neil S Morton
- Department of Anaesthesia, Royal Hospital for Children, Glasgow, UK
| | | | - Mary Ellen McCann
- Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Andrew J Davidson
- Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Anne M Lynn
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
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Willison DJ, Richards DP, Orth A, Harris H, Marlin S. Survey of Awareness and Perceptions of Canadians on the Benefits and Risks of Clinical Trials. Ther Innov Regul Sci 2018; 53:669-677. [PMID: 30373453 PMCID: PMC6710611 DOI: 10.1177/2168479018805433] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background: Little is known about the Canadian public’s perspective regarding clinical trials. Methods: We surveyed 1602 Ontario and British Columbia residents to ascertain their understanding of and willingness to participate in clinical trials. Results: Clinical trials are regarded positively with overall perceptions that they provide societal and personal benefits. Most respondents were somewhat (49%) or very willing (19%) to participate in a clinical trial. This increased with age and level of education. It was also greater among those with poor or very poor health, those with multiple chronic conditions, and those who had previously been invited into a clinical trial, all of which were correlated with age. Still, there was room for improvement in awareness and understanding of clinical trials. Forty-three percent of those surveyed felt not very informed or not at all informed and 37% had no opinion regarding clinical trials. Respondents would most often turn to their treating physician if considering participating in a clinical trial and least often to social media. Conclusion: While Canadians’ views about clinical trials are generally positive, they are somewhat muted and a significant minority feels poorly or not at all informed. They are less willing to participate in clinical research than Americans and are roughly equivalent to Europeans. While clinicians are the top choice for learning about clinical trials, they have little or no training and little time for this role. As we move toward integrating clinical trials into the practice setting, these issues of time, training, and resources must be addressed.
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Affiliation(s)
- Donald J Willison
- 1 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Alison Orth
- 3 Clinical Trials BC, Vancouver, British Columbia, Canada
| | - Heather Harris
- 4 Can-SOLVE CKD Network, Vancouver, British Columbia, Canada
| | - Susan Marlin
- 2 Clinical Trials Ontario, Toronto, Ontario, Canada
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McLennan S, Kahrass H, Wieschowski S, Strech D, Langhof H. The spectrum of ethical issues in a Learning Health Care System: a systematic qualitative review. Int J Qual Health Care 2018; 30:161-168. [PMID: 29394354 DOI: 10.1093/intqhc/mzy005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 01/08/2018] [Indexed: 02/06/2023] Open
Abstract
Purpose To determine systematically the spectrum of ethical issues that is raised for stakeholders in a 'Learning Health Care System' (LHCS). Data sources The systematic review was conducted in PubMed and Google Books between the years 2007 and 2015. Study selection The literature search retrieved 1258 publications. Each publication was independently screened by two reviewers for eligibility for inclusion. Ethical issues were defined as arising when a relevant normative principle is not adequately considered or two principles come into conflict. Data extraction A total of 65 publications were included in the final analysis and were analysed using an adapted version of qualitative content analysis. A coding frame was developed inductively from the data, only the highest-level categories were generated deductively for a life-cycle perspective. Results of data synthesis A total of 67 distinct ethical issues could be categorized under different phases of the LHCS life-cycle. An overarching theme that was repeatedly raised was the conflict between the current regulatory system and learning health care. Conclusion The implementation of a LHCS can help realize the ethical imperative to continuously improve the quality of health care. However, the implementation of a LHCS can also raise a number of important ethical issues itself. This review highlights the importance for health care leaders and policy makers to balance the need to protect and respect individual participants involved in learning health care activities with the social value of improving health care.
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Affiliation(s)
- Stuart McLennan
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.,Institute for Biomedical Ethics, Universität Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
| | - Hannes Kahrass
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Susanne Wieschowski
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Daniel Strech
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Holger Langhof
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Spector-Bagdady K, Jagsi R. Big data, ethics, and regulations: Implications for consent in the learning health system. Med Phys 2018; 45:e845-e847. [PMID: 30144096 DOI: 10.1002/mp.12707] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 11/26/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kayte Spector-Bagdady
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, North Campus Research Complex, 2800 Plymouth Road, Bldg. 14, G016, Ann Arbor, MI, 48109-2800, USA.,Department of Obstetrics and Gynecology, University of Michigan Health System, L4001 Women's Hospital, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-0276, USA
| | - Reshma Jagsi
- Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, North Campus Research Complex, 2800 Plymouth Road, Bldg. 14, G016, Ann Arbor, MI, 48109-2800, USA.,Department of Radiation Oncology, University Hospital B2C490, 1500 East Medical Center Dr, Ann Arbor, MI, 48109-5010, USA
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Bluhm R, Borgerson K. An Epistemic Argument for Research-Practice Integration in Medicine. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2018; 43:469-484. [PMID: 29986063 DOI: 10.1093/jmp/jhy009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Arguments in favor of greater research-practice integration in medicine have tended to be ethical, political, or pragmatic. There are good epistemic reasons to pursue greater integration, and it is important to think through these reasons in order to avoid inadvertently designing new systems in ways that replicate the epistemic elitism common within current systems. Meaningful transformation within health care is possible with close attention to all reasons in favor of greater research-practice integration, including epistemic reasons.
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Affiliation(s)
- Robyn Bluhm
- Michigan State University, East Lansing, Michigan, USA
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Schlesinger M, Grob R. Treating, Fast and Slow: Americans' Understanding of and Responses to Low-Value Care. Milbank Q 2018; 95:70-116. [PMID: 28266067 DOI: 10.1111/1468-0009.12246] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Morain SR, Kass NE, Faden RR. Learning Is Not Enough: Earning Institutional Trustworthiness Through Knowledge Translation. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:31-34. [PMID: 29621442 DOI: 10.1080/15265161.2018.1431708] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
| | - Nancy E Kass
- b Johns Hopkins University and Johns Hopkins Bloomberg School of Public Health
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Kalkman S, Kim SYH, van Thiel GJMW, Grobbee DE, van Delden JJM. Ethics of Informed Consent for Pragmatic Trials with New Interventions. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:902-908. [PMID: 28712619 DOI: 10.1016/j.jval.2017.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 03/30/2017] [Accepted: 04/03/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Pragmatic trials evaluate the comparative benefits, risks, and burdens of health care interventions in real-world conditions. Such studies are now recognized as valuable to the perimarketing stage of drug development and evaluation, with early pragmatic trials (EPTs) being explored as a means to generate real-world evidence at the time of regulatory market approval. In this article, we present an analysis of the ethical issues involved in informed consent for EPTs, in light of the generally recognized concern that traditional ethical rules governing randomized clinical trials, such as lengthy informed consent procedures, could threaten the "real world" nature of such trials. Specifically, we examine to what extent modifications (waivers or alterations) to regulatory consent for EPTs would be ethical. METHODS We first identify broadly accepted necessary conditions for modifications of informed consent (namely, the research involves no more than minimal risk of harm, the research is impracticable with regulatory consent, and the alternative to regulatory consent does not violate legitimate patient expectations) and then apply those criteria to the premarket and early postmarket contexts. RESULTS AND CONCLUSIONS The analysis shows that neither waivers nor alterations of regulatory consent for premarket EPTs will be ethically permissible. For postmarket EPTs with newly approved interventions, waivers of consent will be ethically problematic, but some studies might be conducted in an ethical manner with alterations to regulatory consent.
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Affiliation(s)
- Shona Kalkman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Scott Y H Kim
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Ghislaine J M W van Thiel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes J M van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Jagsi R, Griffith KA, Sabolch A, Jones R, Spence R, De Vries R, Grande D, Bradbury AR. Perspectives of Patients With Cancer on the Ethics of Rapid-Learning Health Systems. J Clin Oncol 2017; 35:2315-2323. [PMID: 28537812 DOI: 10.1200/jco.2016.72.0284] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To inform the evolving implementation of CancerLinQ and other rapid-learning systems for oncology care, we sought to evaluate perspectives of patients with cancer regarding ethical issues. Methods Using the GfK Group online research panel, representative of the US population, we surveyed 875 patients with cancer; 621 (71%) responded. We evaluated perceptions of appropriateness (scored from 1 to 10; 10, very appropriate) using scenarios and compared responses by age, race, and education. We constructed a scaled measure of comfort with secondary use of deidentified medical information and evaluated its correlates in a multivariable model. Results Of the sample, 9% were black and 9% Hispanic; 38% had completed high school or less, and 59% were age ≥ 65 years. Perceptions of appropriateness were highest when consent was obtained and university researchers used data to publish a research study (weighted mean appropriateness, 8.47) and lowest when consent was not obtained and a pharmaceutical company used data for marketing (weighted mean appropriateness, 2.7). Most respondents (72%) thought secondary use of data for research was very important, although those with lower education were less likely to endorse this (62% v 78%; P < .001). Overall, 35% believed it was necessary to obtain consent each time such research was to be performed; this proportion was higher among blacks/Hispanics than others (48% v 33%; P = .02). Comfort with the use of deidentified information from medical records varied by scenario and overall was associated with distrust in the health care system. Conclusion Perceptions of patients with cancer regarding secondary data use depend on the user and the specific use of the data, while also frequently differing by patient sociodemographic factors. Such information is critical to inform ongoing efforts to implement oncology learning systems.
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Affiliation(s)
- Reshma Jagsi
- Reshma Jagsi, Aaron Sabolch, Rochelle Jones, and Raymond De Vries, University of Michigan; Kent A. Griffith, University of Michigan School of Public Health, Ann Arbor, MI; Rebecca Spence, American Society of Clinical Oncology, Alexandria, VA; and David Grande and Angela R. Bradbury, University of Pennsylvania, Philadelphia, PA
| | - Kent A Griffith
- Reshma Jagsi, Aaron Sabolch, Rochelle Jones, and Raymond De Vries, University of Michigan; Kent A. Griffith, University of Michigan School of Public Health, Ann Arbor, MI; Rebecca Spence, American Society of Clinical Oncology, Alexandria, VA; and David Grande and Angela R. Bradbury, University of Pennsylvania, Philadelphia, PA
| | - Aaron Sabolch
- Reshma Jagsi, Aaron Sabolch, Rochelle Jones, and Raymond De Vries, University of Michigan; Kent A. Griffith, University of Michigan School of Public Health, Ann Arbor, MI; Rebecca Spence, American Society of Clinical Oncology, Alexandria, VA; and David Grande and Angela R. Bradbury, University of Pennsylvania, Philadelphia, PA
| | - Rochelle Jones
- Reshma Jagsi, Aaron Sabolch, Rochelle Jones, and Raymond De Vries, University of Michigan; Kent A. Griffith, University of Michigan School of Public Health, Ann Arbor, MI; Rebecca Spence, American Society of Clinical Oncology, Alexandria, VA; and David Grande and Angela R. Bradbury, University of Pennsylvania, Philadelphia, PA
| | - Rebecca Spence
- Reshma Jagsi, Aaron Sabolch, Rochelle Jones, and Raymond De Vries, University of Michigan; Kent A. Griffith, University of Michigan School of Public Health, Ann Arbor, MI; Rebecca Spence, American Society of Clinical Oncology, Alexandria, VA; and David Grande and Angela R. Bradbury, University of Pennsylvania, Philadelphia, PA
| | - Raymond De Vries
- Reshma Jagsi, Aaron Sabolch, Rochelle Jones, and Raymond De Vries, University of Michigan; Kent A. Griffith, University of Michigan School of Public Health, Ann Arbor, MI; Rebecca Spence, American Society of Clinical Oncology, Alexandria, VA; and David Grande and Angela R. Bradbury, University of Pennsylvania, Philadelphia, PA
| | - David Grande
- Reshma Jagsi, Aaron Sabolch, Rochelle Jones, and Raymond De Vries, University of Michigan; Kent A. Griffith, University of Michigan School of Public Health, Ann Arbor, MI; Rebecca Spence, American Society of Clinical Oncology, Alexandria, VA; and David Grande and Angela R. Bradbury, University of Pennsylvania, Philadelphia, PA
| | - Angela R Bradbury
- Reshma Jagsi, Aaron Sabolch, Rochelle Jones, and Raymond De Vries, University of Michigan; Kent A. Griffith, University of Michigan School of Public Health, Ann Arbor, MI; Rebecca Spence, American Society of Clinical Oncology, Alexandria, VA; and David Grande and Angela R. Bradbury, University of Pennsylvania, Philadelphia, PA
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Raymond J, Fahed R, Darsaut TE. Randomize the first patient. J Neuroradiol 2017; 44:291-294. [PMID: 28478113 DOI: 10.1016/j.neurad.2017.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 03/26/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Jean Raymond
- Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Department of Radiology, Montreal, Quebec, Canada.
| | - Robert Fahed
- Centre Hospitalier de l'Université de Montréal (CHUM), Notre-Dame Hospital, Department of Radiology, Montreal, Quebec, Canada
| | - Tim E Darsaut
- University of Alberta Hospital, Mackenzie Health Sciences Centre, Department of Surgery, Division of Neurosurgery, Edmonton, Alberta, Canada
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Chuong KH, Mack DR, Stintzi A, O'Doherty KC. Human Microbiome and Learning Healthcare Systems: Integrating Research and Precision Medicine for Inflammatory Bowel Disease. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2017; 22:119-126. [PMID: 28282257 PMCID: PMC5810428 DOI: 10.1089/omi.2016.0185] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Healthcare institutions face widespread challenges of delivering high-quality and cost-effective care, while keeping up with rapid advances in biomedical knowledge and technologies. Moreover, there is increased emphasis on developing personalized or precision medicine targeted to individuals or groups of patients who share a certain biomarker signature. Learning healthcare systems (LHS) have been proposed for integration of research and clinical practice to fill major knowledge gaps, improve care, reduce healthcare costs, and provide precision care. To date, much discussion in this context has focused on the potential of human genomic data, and not yet on human microbiome data. Rapid advances in human microbiome research suggest that profiling of, and interventions on, the human microbiome can provide substantial opportunity for improved diagnosis, therapeutics, risk management, and risk stratification. In this study, we discuss a potential role for microbiome science in LHSs. We first review the key elements of LHSs, and discuss possibilities of Big Data and patient engagement. We then consider potentials and challenges of integrating human microbiome research into clinical practice as part of an LHS. With rapid growth in human microbiome research, patient-specific microbial data will begin to contribute in important ways to precision medicine. Hence, we discuss how patient-specific microbial data can help guide therapeutic decisions and identify novel effective approaches for precision care of inflammatory bowel disease. To the best of our knowledge, this expert analysis makes an original contribution with new insights poised at the emerging intersection of LHSs, microbiome science, and postgenomics medicine.
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Affiliation(s)
- Kim H Chuong
- 1 Department of Psychology, University of Guelph , Guelph, Ontario, Canada
| | - David R Mack
- 2 Children's Hospital of Eastern Ontario (CHEO) Inflammatory Bowel Disease Centre, University of Ottawa , Ottawa, Ontario, Canada .,3 Department of Pediatrics, Faculty of Medicine, University of Ottawa , Ottawa, Ontario, Canada
| | - Alain Stintzi
- 4 Department of Biochemistry, Microbiology and Immunology, Faculty of Medicine, University of Ottawa , Ottawa, Ontario, Canada
| | - Kieran C O'Doherty
- 1 Department of Psychology, University of Guelph , Guelph, Ontario, Canada
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Raymond J, Darsaut TE, Roy DJ. Recruitment in Clinical Trials: The Use of Zelen's Prerandomization in Recent Neurovascular Studies. World Neurosurg 2017; 98:403-410. [DOI: 10.1016/j.wneu.2016.11.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 11/07/2016] [Accepted: 11/10/2016] [Indexed: 11/17/2022]
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Kraft SA, Constantine M, Magnus D, Porter KM, Lee SSJ, Green M, Kass NE, Wilfond BS, Cho MK. A randomized study of multimedia informational aids for research on medical practices: Implications for informed consent. Clin Trials 2017; 14:94-102. [PMID: 27625314 PMCID: PMC5300898 DOI: 10.1177/1740774516669352] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIMS Participant understanding is a key element of informed consent for enrollment in research. However, participants often do not understand the nature, risks, benefits, or design of the studies in which they take part. Research on medical practices, which studies standard interventions rather than new treatments, has the potential to be especially confusing to participants because it is embedded within usual clinical care. Our objective in this randomized study was to compare the ability of a range of multimedia informational aids to improve participant understanding in the context of research on medical practices. METHODS We administered a web-based survey to members of a proprietary online panel sample selected to match national US demographics. Respondents were randomized to one of five arms: four content-equivalent informational aids (animated videos, slideshows with voice-over, comics, and text) and one no-intervention control. We measured knowledge of research on medical practices using a summary knowledge score from 10 questions based on the content of the informational aids. We used analysis of variance and paired t-tests to compare knowledge scores between arms. RESULTS There were 1500 completed surveys (300 in each arm). Mean knowledge scores were highest for the slideshows with voice-over (65.7%), followed by the animated videos (62.7%), comics (60.7%), text (57.2%), and control (50.3%). Differences between arms were statistically significant except between the slideshows with voice-over and animated videos and between the animated videos and comics. Informational aids that included an audio component (animated videos and slideshows with voice-over) had higher knowledge scores than those without an audio component (64.2% vs 59.0%, p < .0001). There was no difference between informational aids with a character-driven story component (animated videos and comics) and those without. CONCLUSION Our results show that simple multimedia aids that use a dual-channel approach, such as voice-over with visual reinforcement, can improve participant knowledge more effectively than text alone. However, the relatively low knowledge scores suggest that targeted informational aids may be needed to teach some particularly challenging concepts. Nonetheless, our results demonstrate the potential to improve informed consent for research on medical practices using multimedia aids that include simplified language and visual metaphors.
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Affiliation(s)
- Stephanie A Kraft
- Seattle Children’s Research Institute – Treuman Katz Center for Pediatric Bioethics, Seattle, WA USA
| | - Melissa Constantine
- University of Minnesota, Division of Health Policy and Management, Minneapolis, MN USA
| | - David Magnus
- Stanford University School of Medicine – Center for Biomedical Ethics, Stanford, CA USA
| | - Kathryn M. Porter
- Seattle Children’s Research Institute – Treuman Katz Center for Pediatric Bioethics, Seattle, WA USA
| | - Sandra Soo-Jin Lee
- Stanford University School of Medicine – Center for Biomedical Ethics, Stanford, CA USA
| | - Michael Green
- Penn State Milton S Hershey Medical Center – College of Medicine, Hershey, PA USA
| | - Nancy E Kass
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD USA
| | - Benjamin S. Wilfond
- Seattle Children’s Research Institute – Treuman Katz Center for Pediatric Bioethics, Seattle, WA USA
| | - Mildred K Cho
- Stanford University School of Medicine – Center for Biomedical Ethics, Stanford, CA USA
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Platt JE, Jacobson PD, Kardia SLR. Public Trust in Health Information Sharing: A Measure of System Trust. Health Serv Res 2017; 53:824-845. [PMID: 28097657 DOI: 10.1111/1475-6773.12654] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To measure public trust in a health information sharing in a broadly defined health system (system trust), inclusive of health care, public health, and research; to identify individual characteristics that predict system trust; and to consider these findings in the context of national health initiatives (e.g., learning health systems and precision medicine) that will expand the scope of data sharing. DATA SOURCES Survey data (n = 1,011) were collected in February 2014. STUDY DESIGN We constructed a composite index of four dimensions of system trust-competency, fidelity, integrity, and trustworthiness. The index was used in linear regression evaluating demographic and psychosocial predictors of system trust. DATA COLLECTION Data were collected by GfK Custom using a nationally representative sample and analyzed in Stata 13.0. PRINCIPAL FINDINGS Our findings suggest the public's trust may not meet the needs of health systems as they enter an era of expanded data sharing. We found that a majority of the U.S. public does not trust the organizations that have health information and share it (i.e., the health system) in one or more dimensions. Together, demographic and psychosocial factors accounted for ~18 percent of the observed variability in system trust. Future research should consider additional predictors of system trust such as knowledge, attitudes, and beliefs to inform policies and practices for health data sharing.
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Affiliation(s)
- Jodyn E Platt
- Division of Learning and Knowledge Systems, Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI
| | - Peter D Jacobson
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Sharon L R Kardia
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
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Implementing Precision Medicine: The Ethical Challenges. Trends Pharmacol Sci 2016; 38:8-14. [PMID: 27939182 DOI: 10.1016/j.tips.2016.11.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 11/09/2016] [Accepted: 11/09/2016] [Indexed: 01/08/2023]
Abstract
Precision medicine aims to individualize care by understanding differences in genetics, lifestyle, and environment. Pharmacogenomics and cancer genetics represent two promising areas for this approach. Pharmacogenomic tests have the potential to direct drug prescribing to increase safety and effectiveness because individuals vary on a genetic basis in their response to many drugs. Similarly, tests to identify people with an inherited cancer risk can guide prevention. For both, a few tests have entered clinical practice and more are under development. Implementation challenges include the limited evidence base available to guide clinical use and the lack of data from diverse populations. Accordingly, ongoing research should prioritize procedures that enhance the trustworthiness of clinical practice guidelines and create decision support for clinicians and patients that address their needs and accommodate flexibility. Each step involves choices with ethical implications.
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Proposals to Conduct Randomized Controlled Trials Without Informed Consent: a Narrative Review. J Gen Intern Med 2016; 31:1511-1518. [PMID: 27384536 PMCID: PMC5130947 DOI: 10.1007/s11606-016-3780-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 06/06/2016] [Accepted: 06/08/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Individual informed consent from all participants is required for most randomized clinical trials (RCTs). However, some exceptions-for example, emergency research-are widely accepted. METHODS The literature on various approaches to randomization without consent (RWOC) has never been systematically reviewed. Our goal was to provide a survey and narrative synthesis of published proposals for RWOC. We focused on proposals to randomize at least some participants in a study without first obtaining consent to randomization. This definition included studies that omitted informed consent entirely, omitted informed consent for selected patients (e.g., the control group), obtained informed consent to research but not to randomization, or only obtained informed consent to randomization after random assignment had already occurred. It omitted oral and staged consent processes that still obtain consent to randomization from all participants before randomization occurs. RESULTS We identified ten different proposals for RWOC: two variants of cluster randomization, two variants of the Zelen design, consent to postponed information, two-stage randomized consent, cohort multiple RCT, emergency research, prompted optional randomization trials, and low-risk pragmatic RCTs without consent. CONCLUSION Of all designs discussed here, only cluster randomized designs and emergency research are routinely used, with the justification that informed consent is infeasible in those settings. Other designs have raised concerns that they do not appropriately respect patient autonomy. Recent proposals have emphasized the importance for RWOC of demonstrating such respect through systematic patient engagement, transparency, and accountability, potentially in the context of learning health care systems.
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Kraft SA, Cho MK, Constantine M, Lee SSJ, Kelley M, Korngiebel D, James C, Kuwana E, Meyer A, Porter K, Diekema D, Capron AM, Alicic R, Wilfond BS, Magnus D. A comparison of institutional review board professionals' and patients' views on consent for research on medical practices. Clin Trials 2016; 13:555-65. [PMID: 27257125 PMCID: PMC5025342 DOI: 10.1177/1740774516648907] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND/AIMS In the context of research on medical practices, which includes comparative effectiveness research and pragmatic clinical trials, empirical studies have begun to raise questions about the extent to which institutional review boards' interpretations and applications of research regulations align with patients' values. To better understand the similarities and differences between these stakeholder groups, we compare and contrast two surveys: one of institutional review board professionals and one of patients, which examine views on consent for research on medical practices. METHODS We conducted online surveys of two target populations between July 2014 and March 2015. We surveyed 601 human subjects research professionals out of 1500 randomly selected from the Public Responsibility in Medicine and Research membership list (40.1% response rate), limiting analysis to 537 respondents who reported having had institutional review board experience. We also surveyed 120 adult patients out of 225 approached at subspecialty clinics in Spokane, Washington (53.3% response rate). Our survey questions probed attitudes about consent in the context of research on medical practices using medical record review and randomization. The patient survey included three embedded animated videos to explain these concepts. RESULTS A majority of institutional review board professionals distinguished between consent preferences for medical record review and randomization, ranked clinicians as the least preferred person to obtain participant consent (54.6%), and viewed written or verbal permission as the minimum acceptable consent approach for research on medical practices using randomization (87.3%). In contrast, most patients had similar consent preferences for research on medical practices using randomization and medical record review, most preferred to have consent conversations with their doctors rather than with researchers for studies using randomization (72.6%) and medical record review (67.0%), and only a few preferred to see research involving randomization (16.8%) or medical record review (13.8%) not take place if obtaining written or verbal permission would make the research too difficult to conduct. Limitations of our post hoc analysis include differences in framing, structure, and language between the two surveys and possible response bias. CONCLUSION Our findings highlight a need to identify appropriate ways to integrate patient preferences into prevailing regulatory interpretations as institutional review boards increasingly apply research regulations in the context of research on medical practices. Dialogue between institutional review boards and research participants will be an important part of this process and should inform future regulatory guidance.
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Affiliation(s)
| | - Mildred K Cho
- Stanford Center for Biomedical Ethics, Stanford, CA, USA
| | - Melissa Constantine
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | | | - Maureen Kelley
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Diane Korngiebel
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA
| | - Cyan James
- Institute for Public Health Genetics, University of Washington, Seattle, WA, USA
| | - Ellen Kuwana
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
| | - Adrienne Meyer
- Human Subjects Division, University of Washington, Seattle, WA, USA
| | - Kathryn Porter
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
| | - Douglas Diekema
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
| | - Alexander M Capron
- USC Gould School of Law, University of Southern California, Los Angeles, CA, USA
| | - Radica Alicic
- Providence Medical Research Center, Spokane, WA, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford, CA, USA
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Condit CM, Shen L, Edwards KL, Bowen DJ, Korngiebel DM, Johnson CO. Participants' Role Expectations in Genetics Research and Re-consent: Revising the Theory and Methods of Mental Models Research Relating to Roles. JOURNAL OF HEALTH COMMUNICATION 2016; 21:16-24. [PMID: 27653592 PMCID: PMC7868084 DOI: 10.1080/10810730.2016.1193914] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The rise of large cohort-based health research that includes genetic components has increased the communication challenges for researchers. Controversies have been amplified over requirements for re-consent, return of results, and privacy protections, among other issues. This study extended research on the impact that the perceived role of "research participant" might have on communication expectations to illuminate research participants' preferences for re-consent. The study employed an online survey of participants in a long-standing cancer genetics registry. Results confirmed previous exploratory findings that research participants endorse multiple mental models of participant roles in research (doctor-patient, collaborator, donor, legal contract, etc.). Regression analyses indicated that high and low salience of different models of the role of research participant are related to different communication expectations. However, the pattern of relationships among roles is relevant. The results of the regression analysis also indicated that preference for mandatory re-consent and its relationship to mental models of roles are related to attitudes of trust, benefits, and informational risks. The discussion identifies implications as including the use of explicit approaches to address role relationships in communication with research participants. It also points to implications for methodological approaches in mental model research.
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Affiliation(s)
- Celeste M Condit
- a Department of Communication Studies , University of Georgia , Athens , Georgia , USA
| | - Lijiang Shen
- b Department of Communication Arts and Sciences , Pennsylvania State University , University Park , Pennsylvania , USA
| | - Karen L Edwards
- c Department of Epidemiology, School of Medicine , University of California, Irvine , Irvine , California , USA
| | - Deborah J Bowen
- d Department of Bioethics and Humanities , University of Washington , Seattle , Washington , USA
| | - Diane M Korngiebel
- e Biomedical Informatics and Medical Education , University of Washington , Seattle , Washington , USA
| | - Catherine O Johnson
- c Department of Epidemiology, School of Medicine , University of California, Irvine , Irvine , California , USA
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Lee SSJ, Kelley M, Cho MK, Kraft SA, James C, Constantine M, Meyer AN, Diekema D, Capron AM, Wilfond BS, Magnus D. Adrift in the Gray Zone: IRB Perspectives on Research in the Learning Health System. AJOB Empir Bioeth 2016; 7:125-134. [PMID: 27917391 DOI: 10.1080/23294515.2016.1155674] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Human subjects protection in healthcare contexts rests on the premise that a principled boundary distinguishes clinical research and clinical practice. However, growing use of evidence-based clinical practices by health systems makes it increasingly difficult to disentangle research from a wide range of clinical activities that are sometimes called "research on medical practice" (ROMP), including quality improvement activities and comparative effectiveness research. The recent growth of ROMP activities has created an ethical and regulatory gray zone with significant implications for the oversight of human subjects research. METHODS We conducted six semi-structured, open-ended focus group discussions with IRB members to understand their experiences and perspectives on ethical oversight of ROMP, including randomization of patients to standard treatments. RESULTS Our study revealed that IRB members are unclear or divided on the central questions at stake in the current policy debate over ethical oversight of ROMP: IRB members struggle to make a clear distinction between clinical research and medical practice improvement, lack consensus on when ROMP requires IRB review and oversight, and are uncertain about what constitutes incremental risk when patients are randomized to different treatments, any of which may be offered in usual care. They characterized the central challenge as a balancing act, between, on the one hand, making information fully transparent to patients and providing adequate oversight, and on the other hand, avoiding a chilling effect on the research process or harming the physician-patient relationship. CONCLUSIONS Evidence-based guidance that supports IRB members in providing adequate and effective oversight of ROMP without impeding the research process or harming the physician-patient relationship is necessary to realize the full benefits of the learning health system.
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