Do patient consent procedures affect participation rates in health services research?

Feasibility Pilot Study of an Opioid Helpline for Individuals at High Risk for Opioid Use Disorder

BACKGROUND

Evidence suggests that educational interventions delivered by healthcare providers can be effective in altering patients' attitudes toward pain management and in referral to addiction treatment when appropriate. Time constraints during visits limit the delivery of such important interventions.

OBJECTIVE

This study aims to explore the feasibility and perceived value of an opioid helpline that provides resources to individuals suffering from or at risk for opioid use disorder.

METHODS

We developed a helpline with a toll-free number "1-877 OPIOIDS (6437)" established through the University of Virginia, which runs Monday through Friday from 8:30 am to 5 pm and is answered by a live answering service after hours. The helpline offered a range of resources including opioid pain medication education, signs of overdose or withdrawal, addiction treatment options, and connection to treatment services. The helpline was supported by outreach efforts to surrounding counties in Virginia. Questionnaires on perceived usefulness were sent to callers and providers who used or offered the helpline in their clinics. Survey data were analyzed to identify trends.

RESULTS

Thirty-one consented individuals of 166 contacts were included in the study. Although participants were referred to the helpline through a variety of sources, most were referred by a physician (38.7%). Most participants rated the helpline's helpfulness with the highest satisfaction score (81.5%). Most individuals seeking addiction treatment found the helpline to be useful, whereas those referred by their respective physician to gain more information about their opioid use and prevent escalation to addiction felt it was an unnecessary step.

CONCLUSIONS

Our pilot study demonstrated that a helpline could be an additional tool to combat the opioid crisis. Individual callers rated the intervention favorably. Our study shows that the most substantial area of satisfaction for our participants is being able to reach a live person when in need.

A prospective evaluation of the clinical safety and effectiveness of a COVID-19 Urgent Eyecare Service across five areas in England

Purpose

Although urgent primary eye care schemes exist in some areas of England, their current safety is unknown. Accordingly, the aim of the present study was to quantify the clinical safety and effectiveness of a COVID‐19 Urgent Eyecare Service (CUES) across Luton, Bedford, Hull, East Riding of Yorkshire and Harrogate.

Methods

Consenting patients with acute onset eye problems who had accessed the service were contacted to ascertain what the optometrist's recommendation was, whether this worked, if they had to present elsewhere and how satisfied they were with the CUES.

Results

A total of 27% (170/629) and 6.3% (28/445) of patients managed virtually and in person, respectively, did not have their acute eye problem resolved. Regression analysis revealed that patients who attended a face‐to‐face consultation were 4.66 times more likely to be correctly managed [Exp (β) = 5.66], relative to those solely managed virtually. Optometrists' phone consultations failed to detect conditions such as stroke, intracranial hypertension, suspected space occupying lesions, orbital cellulitis, scleritis, corneal ulcer, wet macular degeneration, uveitis with macular oedema and retinal detachment. Of referrals to hospital ophthalmology departments, in total, 19% were false‐positives. Patients, however, were typically very satisfied with the service. Uptake was associated with socioeconomic status.

Conclusion

The present study found that a virtual assessment service providing optometrist tele‐consultations was not effective at resolving patients' acute‐onset eye problems. The range and number of pathologies missed by tele‐consultations suggests that the service model in the present study was detrimental to patient safety. To improve this, optometrists should follow evidence based guidance when attempting to manage patients virtually, or in person. For example, patients presenting with acute‐onset symptoms of flashing lights and/or floaters require an urgent dilated fundus examination. Robust data collection on service safety is required on an ongoing basis.

A systematic literature review of attitudes towards secondary use and sharing of health administrative and clinical trial data: a focus on consent

BACKGROUND

We aimed to synthesise data on issues related to stakeholder perceptions of consent for the use of secondary data. To better understand the current literature available, we conducted a systematic literature review of healthcare consumer attitudes towards the secondary use and sharing of health administrative and clinical trial data.

METHODS

EMBASE/MEDLINE, Cochrane Library, PubMed, CINAHL, Informit Health Collection, PROSPERO Database of Systematic Reviews, PsycINFO and ProQuest databases were searched. Eligible articles included those reporting qualitative or quantitative original research and published in English. No restrictions were placed on publication dates, study design or disease setting. One author screened articles for eligibility and two authors were involved in the full-text review process. Conflicts were resolved by consensus. Quality and bias were assessed using the QualSyst criteria for qualitative studies.

RESULTS

This paper focuses on a subset of 47 articles identified from the wider search and focuses on the issue of consent. Issues related to privacy, trust and transparency, and attitudes of healthcare professionals and researchers to secondary use and sharing of data have been dealt with in previous publications. Studies included a total of 216,149 respondents. Results indicate that respondents are generally supportive of using health data for research, particularly if the data is de-identified or anonymised. The requirement by participants to obtain consent prior to the use of health data for research was not universal, nor is the requirement for this always supported by legislation. Many respondents believed that either no consent or being informed of the research, but not providing additional consent, were sufficient.

CONCLUSIONS

These results indicate that individuals should be provided with information and choice about how their health data is used and, where feasible, a mechanism to opt-out should be provided. To increase the acceptability of using health data for research, health organisations and data custodians must provide individuals with concise information about data protection mechanisms and under what circumstances their data may be used and by whom.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018110559 (update June 2020).

Public Interest, Health Research and Data Protection Law: Establishing a Legitimate Trade-Off between Individual Control and Research Access to Health Data

The United Kingdom’s Data Protection Act 2018 introduces a new public interest test applicable to the research processing of personal health data. The need for interpretation and application of this new safeguard creates a further opportunity to craft a health data governance landscape deserving of public trust and confidence. At the minimum, to constitute a positive contribution, the new test must be capable of distinguishing between instances of health research that are in the public interest, from those that are not, in a meaningful, predictable and reproducible manner. In this article, we derive from the literature on theories of public interest a concept of public interest capable of supporting such a test. Its application can defend the position under data protection law that allows a legal route through to processing personal health data for research purposes that does not require individual consent. However, its adoption would also entail that the public interest test in the 2018 Act could only be met if all practicable steps are taken to maximise preservation of individual control over the use of personal health data for research purposes. This would require that consent is sought where practicable and objection respected in almost all circumstances. Importantly, we suggest that an advantage of relying upon this concept of the public interest, to ground the test introduced by the 2018 Act, is that it may work to promote the social legitimacy of data protection legislation and the research processing that it authorises without individual consent (and occasionally in the face of explicit objection).

Recruitment of trial participants through electronic medical record patient portal messaging: A pilot study

BACKGROUND/AIM

Cost-efficient methods are essential for successful participant recruitment in clinical trials. Patient portal messages are an emerging means of recruiting potentially eligible patients into trials. We assessed the response rate and complaint rate from direct-to-patient, targeted recruitment through patient portals of an electronic medical record for a clinical trial, and compared response rates by differences in message content.

METHODS

The Study to Understand Fall Reduction and Vitamin D in You (STURDY) trial is a National Institutes of Health-sponsored, community-based study of vitamin D supplementation for fall prevention in older adults conducted at Johns Hopkins. Potential participants were identified using the Epic electronic medical record at the Johns Hopkins Health System based on age (≥70 years), ZIP code (30-mile radius of study site), and prior activation of a patient portal account. We prepared a shorter message and a longer message. Both had basic information about study participation, but the longer message also contained information about the significance of the study and a personal invitation from the STURDY principal investigator. The Hopkins Institutional Review Board did not require prior consent from the patient or their providers. We calculated the response rate and tracked the number of complaints and requests for removal from future messages. We also determined response rate according to message content.

RESULTS

Of the 5.5 million individuals receiving care at the Johns Hopkins Health System, a sample of 6896 met our inclusion criteria and were sent one patient portal recruitment message between 6 April 2017 and 3 August 2017. Assessment of enrollment by this method ended on 1 December 2017. There were 116 patients who expressed interest in the study (response rate: 1.7%). Twelve (0.2%) recipients were randomized. There were two complaints (0.03%) and one request to unsubscribe from future recruitment messages (0.01%). Response rate was higher with the longer message than the shorter message (2.1% vs 1.2%; p = 0.005).

CONCLUSION

Patient portal messages inviting seniors to participate in a randomized controlled trial resulted in a response rate similar to commercial email marketing and resulted in very few complaints or opt-out requests. Furthermore, a longer message with more content enhanced response rate. Recruitment through patient portals might be an effective strategy to enroll trial participants.

Barriers to Recruitment in Pediatric Obesity Trials: Comparing Opt-in and Opt-out Recruitment Approaches

Objective

To compare the efficacy of opt-in versus opt-out recruitment methods in pediatric weight management clinical trials.

Methods

Recruitment of preschoolers and school-age children across two obesity randomized controlled trials (RCTs) were compared using the same opt-in recruitment approach (parents contact researchers in response to mailings). Opt-in and opt-out strategies (parents send decline postcard in response to mailings if they do not want to participate) were then compared across two preschool obesity RCTs.

Results

Opt-in strategies yielded a significantly lower overall recruitment rate among preschoolers compared with school-age children. Among preschoolers, an opt-out strategy demonstrated a significantly higher overall recruitment rate compared with an opt-in strategy with the main advantage in the number of families initially contacted.

Conclusions

Opt-out recruitment strategies may be more effective in overcoming the barriers of recruitment in the preschool age-group because it does not rely on parent recognition of obesity.

A scoping review to explore the suitability of interactive voice response to conduct automated performance measurement of the patient's experience in primary care

INTRODUCTION

Practice-based performance measurement is fundamental for improvement and accountability in primary care. Traditional performance measurement of the patient's experience is often too costly and cumbersome for most practices.

OBJECTIVE/METHODS

This scoping review explores the literature on the use of interactive voice response (IVR) telephone surveys to identify lessons for its use for collecting data on patient-reported outcome measures at the primary care practice level.

RESULTS

The literature suggests IVR could potentially increase the capacity to reach more representative patient samples and those traditionally most difficult to engage. There is potential for long-term cost effectiveness and significant decrease of the burden on practices involved in collecting patient survey data. Challenges such as low response rates, mode effects, high initial set-up costs and maintenance fees, are also reported and require careful attention.

CONCLUSION

This review suggests IVR may be a feasible alternative to traditional patient data collection methods, which should be further explored.

A Scoping Review of Empirical Research Relating to Quality and Effectiveness of Research Ethics Review

Background

To date there is no established consensus of assessment criteria for evaluating research ethics review.

Methods

We conducted a scoping review of empirical research assessing ethics review processes in order to identify common elements assessed, research foci, and research gaps to aid in the development of assessment criteria. Electronic searches of Ovid Medline, PsychInfo, and the Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, and NHSEED, were conducted. After de-duplication, 4234 titles and abstracts were reviewed. Altogether 4036 articles were excluded following screening of titles, abstracts and full text. A total of 198 articles included for final data extraction.

Results

Few studies originated from outside North America and Europe. No study reported using an underlying theory or framework of quality/effectiveness to guide study design or analyses. We did not identify any studies that had involved a controlled trial - randomised or otherwise – of ethics review procedures or processes. Studies varied substantially with respect to outcomes assessed, although tended to focus on structure and timeliness of ethics review.

Discussion

Our findings indicate a lack of consensus on appropriate assessment criteria, exemplified by the varied study outcomes identified, but also a fragmented body of research. To date research has been largely quantitative, with little attention given to stakeholder experiences, and is largely cross sectional. A lack of longitudinal research to date precludes analyses of change or assessment of quality improvement in ethics review.

Using police crash databases for injury prevention research - a comparison of opt-out and opt-in approaches to study recruitment

OBJECTIVE

The study aimed to examine the difference in response rates between opt-out and opt-in participant recruitment in a population-based study of heavy-vehicle drivers involved in a police-attended crash.

METHODS

Two approaches to subject recruitment were implemented in two different states over a 14-week period and response rates for the two approaches (opt-out versus opt-in recruitment) were compared.

RESULTS

Based on the eligible and contactable drivers, the response rates were 54% for the opt-out group and 16% for the opt-in group.

CONCLUSIONS AND IMPLICATIONS

The opt-in recruitment strategy (which was a consequence of one jurisdiction's interpretation of the national Privacy Act at the time) resulted in an insufficient and potentially biased sample for the purposes of conducting research into risk factors for heavy-vehicle crashes. Australia's national Privacy Act 1988 has had a long history of inconsistent practices by state and territory government departments and ethical review committees. These inconsistencies can have profound effects on the validity of research, as shown through the significantly different response rates we reported in this study. It is hoped that a more unified interpretation of the Privacy Act across the states and territories, as proposed under the soon-to-be-released Australian Privacy Principles(1) will reduce the recruitment challenges outlined in this study.

Research in the CKD clinic: highs and lows

Despite rates of CKD continuing to increase, the current evidence base used to guide CKD management is smaller than that for many other chronic diseases. Clinical investigators face multiple barriers to conducting research in patients with CKD. CKD patients have multiple comorbidities that make them a risky intervention target; thus, they are often excluded from trials. The lack of approved surrogate endpoints for kidney disease progression makes testing therapies to slow progression very challenging and expensive. Patients with CKD have higher rates of disability and lower educational status than the general population, which further complicates their participation in clinical trials. Despite these barriers, it is imperative that scientific progress be made in this patient population. Increasing education and information regarding CKD clinical trials through brochures and public awareness campaigns may increase trial participation. The U.S. Food and Drug Administration needs to approve the new definition of glomerular filtration rate decline because this will result in a decrease in the cost of clinical trials and make industry more likely to invest in trials in patients with CKD. Successful research in this patient population is possible, but it requires collaboration among investigators, health-care providers, patients, industry, and the National Institutes of Health.

Participant recruitment in sensitive surveys: a comparative trial of 'opt in' versus 'opt out' approaches

Background

Although in health services survey research we strive for a high response rate, this must be balanced against the need to recruit participants ethically and considerately, particularly in surveys with a sensitive nature. In survey research there are no established recommendations to guide recruitment approach and an ‘opt-in’ system that requires potential participants to request a copy of the questionnaire by returning a reply slip is frequently adopted. However, in observational research the risk to participants is lower than in clinical research and so some surveys have used an ‘opt-out’ system. The effect of this approach on response and distress is unknown. We sought to investigate this in a survey of end of life care completed by bereaved relatives.

Methods

Out of a sample of 1422 bereaved relatives we assigned potential participants to one of two study groups: an ‘opt in’ group (n=711) where a letter of invitation was issued with a reply slip to request a copy of the questionnaire; or an ‘opt out’ group (n=711) where the survey questionnaire was provided alongside the invitation letter. We assessed response and distress between groups.

Results

From a sample of 1422, 473 participants returned questionnaires. Response was higher in the ‘opt out’ group than in the ‘opt in’ group (40% compared to 26.4%: χ² =29.79, p-value<.01), there were no differences in distress or complaints about the survey between groups, and assignment to the ‘opt out’ group was an independent predictor of response (OR=1.84, 95% CI: 1.45-2.34). Moreover, the ‘opt in’ group were more likely to decline to participate (χ²=28.60, p-value<.01) and there was a difference in the pattern of questionnaire responses between study groups.

Conclusion

Given that the ‘opt out’ method of recruitment is associated with a higher response than the ‘opt in’ method, seems to have no impact on complaints or distress about the survey, and there are differences in the patterns of responses between groups, the ‘opt out’ method could be recommended as the most efficient way to recruit into surveys, even in those with a sensitive nature.

U. S. Health Researchers Review their Ethics Review Boards: A Qualitative Study

VIRTUALLY ALL RESEARCH INVOLVING HUMAN subjects in the United States must be reviewed by an institutional review board, a form of research ethics review board. This article reports the results of qualitative research on how investigators regard this regulatory regime. Interviews were conducted with forty investigators conducting health-related research. Most respondents shared the regulations' goals, but doubted that the regulations, as implemented, promoted these goals efficiently, effectively and fairly. The interviews suggest that efforts to raise researchers' ethical consciousness have been, over time, quite successful, but that implementation of the regulations remains problematic. Research aimed at better defining the problem to be solved b y the r egulatory sy stem, and at a ssessing the effectiveness of the regulatory tools for solving properly defined problems, could guide a more productive debate about human subject protection.

Recruitment and follow-up of adolescent and young adult cancer survivors: the AYA HOPE Study

INTRODUCTION

Cancer is rare in adolescents and young adults (AYA), but these patients have seen little improvement in survival in contrast to most other age groups. Furthermore, participation in research by AYAs is typically low. We conducted a study to examine the feasibility of recruiting a population-based sample of AYA survivors to examine issues of treatment and health outcomes.

METHODS

Individuals diagnosed in 2007-08 and age 15-39 at the time of diagnosis with acute lymphocytic leukemia, Hodgkin lymphoma, non-Hodgkin lymphoma, germ cell cancer or sarcoma were identified by 7 Surveillance, Epidemiology, and End-Results (SEER) cancer registries, mailed surveys within 14 months after diagnosis and again a year later, and had medical records reviewed.

RESULTS

525 (43%) of the eligible patients responded, 39% refused and 17% were lost to follow-up. Extensive efforts were required for most potential respondents (87%). 76% of respondents completed the paper rather than online survey version. In a multivariate model, age, cancer site, education and months from diagnosis to the first mailing of the survey were not associated with participation, although males (p  <  0.01), Hispanics and non-Hispanic blacks (p  <  0.001) were less likely to participate. 91% of survivors completing the initial survey completed the subsequent survey.

DISCUSSION

Despite the response rate, those who participated adequately reflected the population of AYA cancer survivors. The study demonstrates that cancer registries are valuable foundations for conducting observational, longitudinal population-based research on AYA cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Achieving a reasonable response rate in this population is possible, but requires extensive resources.

Using different approaches to conducting postal questionnaires affected response rates and cost-efficiency

OBJECTIVE

To compare three different approaches for consent in postal questionnaire in terms of response rate, time consumption, and cost-efficiency, and to collect a demographic questionnaire for dropout analyses.

STUDY DESIGN AND SETTING

Population survey in Sweden. Mothers and fathers (n=600) of three hundred 3-year olds were divided into three groups. One group was asked to Actively Agree to participate in a cover letter and send consent back to receive the main questionnaire. The second group received the cover letter, the consent, and the main questionnaire in the initial mailings, Direct Delivery. The third group received the cover letter and consent form in which they were asked to Actively Decline participation within 7 days if they did not want to participate. Otherwise, they were sent the main questionnaire. All parents were asked to fill in a demographic questionnaire regardless of whether they wanted to complete the main questionnaire.

RESULTS

The highest response rate was in the Actively Decline mode. The cost-efficiency for this approach was 1.52 compared with Direct Delivery and 1.29 compared with Actively Agree.

CONCLUSION

Researchers can improve the response rate, time consumption, and cost-efficiency and obtain a demographic questionnaire for dropout analysis by using the Actively Decline approach for postal questionnaires.

America's "undiscovered" laboratory for health services research

Debate over reforming the nation's healthcare system has stimulated a need for health services research (HSR) models that are nationally applicable. Toward this end, the authors identify the Military Health System (MHS) as America's "undiscovered" laboratory for HSR. Although many may confuse the MHS with the Department of Veterans Affairs (VA), the 2 systems vary dramatically with respect to their beneficiary populations, access to care, and other important attributes. In this article, the authors describe key characteristics of the MHS including its large beneficiary base, its direct care operating environment, its dedicated medical school and graduate education programs, and its fully operational integrated health information system. Although a few health systems (eg, Kaiser Permanente, Partners Healthcare, and Department of Veterans Affairs) possess some characteristics, no other has all of these components in place. This article sets the stage for contemporary HSR studies with broad applicability to current issues in American healthcare that could be performed within the MHS. Inclusion of the MHS environment in HSR studies of health services delivery modalities, adoption of health information technology, access to care, relationship of medical education to effective safe care delivery, health disparities, child health, and behavioral health would provide strong underpinnings for proposed changes in American healthcare delivery. Finally, the article highlights current regulatory barriers to research within the MHS whereas suggesting steps to minimize their impact in conducting HSR.

Public opinions about participating in health research

OBJECTIVES

Privacy legislation has limited options for recruiting subjects to health studies. Policy changes are motivated by assumptions about public attitudes towards participation, yet surveys of attitudes have rarely been done. We investigated public willingness to participate in health research and how willingness was affected by various factors.

METHODS

A survey of adults randomly selected from the telephone directory was conducted in British Columbia, Canada. Mailed self-administered questionnaires asked about willingness to participate in health research and the influence on willingness of the method of subject selection, the organization making the contact, and other factors.

RESULTS

There were 1,477 respondents (58% of eligible); 85% were willing to participate in health research at least sometimes. The organization making the contact influenced comfort about participation: 10% of respondents felt uncomfortable if contacted by a university, 12% if by a hospital, 26% if by government, and 55% if by private research firms. Factors most positively influencing choice to participate were future health benefits to society (87%) and oneself (87%), and receiving a copy of the study results (81%).

CONCLUSIONS

Participation in health research appears to be viewed favourably by members of the public, and participation may be highest when university or hospital-based researchers are able to contact subjects directly using information from government databases.

Challenges in evaluating Welfare to Work policy interventions: would an RCT design have been the answer to all our problems?

Background

UK policy direction for recipients of unemployment and sickness benefits is to support these people into employment by increasing 'into work' interventions. Although the main aim of associated interventions is to increase levels of employment, improved health is stated as a benefit, and a driver of these interventions. This is therefore a potentially important policy intervention with respect to health and health inequalities, and needs to be validated through rigorous impact evaluation.

We attempted to evaluate the Pathways Advisory Service intervention which aims to provide employment support for Incapacity Benefit recipients, but encountered a number of challenges and barriers to evaluation. This paper explores the issues that arose in designing a suitable evaluation of the Pathways Advisory Service.

Discussion

The main issues that arose were that characteristics of the intervention lead to difficulties in defining a suitable comparison group; and governance restrictions such as uncertainty regarding ethical consent processes and data sharing between agencies for research. Some of these challenges threatened fundamentally to limit the validity of any experimental or quasi-experimental evaluation we could design - restricting recruitment, data collection and identification of an appropriate comparison group. Although a cluster randomised controlled trial design was ethically justified to evaluate the Pathways Advisory Service, this was not possible because the intervention was already being widely implemented. However, this would not have solved other barriers to evaluation. There is no obvious method to perform a controlled evaluation for interventions where only a small proportion of those eligible are exposed. Improved communication between policymakers and researchers, clarification of data sharing protocols and improved guidelines for ethics committees are tangible ways which may reduce the current obstacles to this and other similar evaluations of policy interventions which tackle key determinants of health.

Summary

The evaluation of social interventions is hampered by more than their suitability to randomisation. Data sharing, participant identification and recruitment problems are common to randomised and non-randomised evaluation designs. These issues require further attention if we are to learn from current social policy.

Evaluating predictors of geographic area population size cut-offs to manage re-identification risk

OBJECTIVE

In public health and health services research, the inclusion of geographic information in data sets is critical. Because of concerns over the re-identification of patients, data from small geographic areas are either suppressed or the geographic areas are aggregated into larger ones. Our objective is to estimate the population size cut-off at which a geographic area is sufficiently large so that no data suppression or further aggregation is necessary.

DESIGN

The 2001 Canadian census data were used to conduct a simulation to model the relationship between geographic area population size and uniqueness for some common demographic variables. Cut-offs were computed for geographic area population size, and prediction models were developed to estimate the appropriate cut-offs.

MEASUREMENTS

Re-identification risk was measured using uniqueness. Geographic area population size cut-offs were estimated using the maximum number of possible values in the data set and a traditional entropy measure.

RESULTS

The model that predicted population cut-offs using the maximum number of possible values in the data set had R2 values around 0.9, and relative error of prediction less than 0.02 across all regions of Canada. The models were then applied to assess the appropriate geographic area size for the prescription records provided by retail and hospital pharmacies to commercial research and analysis firms.

CONCLUSIONS

To manage re-identification risk, the prediction models can be used by public health professionals, health researchers, and research ethics boards to decide when the geographic area population size is sufficiently large.

Ethical dilemmas of a large national multi-centre study in Australia: time for some consistency

AIMS AND OBJECTIVES

To examine the impact and obstacles that individual Institutional Research Ethics Committee (IRECs) had on a large-scale national multi-centre clinical audit called the National Benchmarks and Evidence-based National Clinical guidelines for Heart failure management programmes Study.

BACKGROUND

Multi-centre research is commonplace in the health care system. However, IRECs continue to fail to differentiate between research and quality audit projects.

METHODS

The National Benchmarks and Evidence-based National Clinical guidelines for Heart failure management programmes study used an investigator-developed questionnaire concerning a clinical audit for heart failure programmes throughout Australia. Ethical guidelines developed by the National governing body of health and medical research in Australia classified the National Benchmarks and Evidence-based National Clinical guidelines for Heart failure management programmes Study as a low risk clinical audit not requiring ethical approval by IREC.

RESULTS

Fifteen of 27 IRECs stipulated that the research proposal undergo full ethical review. None of the IRECs acknowledged: national quality assurance guidelines and recommendations nor ethics approval from other IRECs. Twelve of the 15 IRECs used different ethics application forms. Variability in the type of amendments was prolific. Lack of uniformity in ethical review processes resulted in a six- to eight-month delay in commencing the national study.

CONCLUSIONS

Development of a national ethics application form with full ethical review by the first IREC and compulsory expedited review by subsequent IRECs would resolve issues raised in this paper. IRECs must change their ethics approval processes to one that enhances facilitation of multi-centre research which is now normative process for health services.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study highlight inconsistent ethical requirements between different IRECs. Also highlighted are the obstacles and delays that IRECs create when undertaking multi-centre clinical audits. However, in our clinical practice it is vital that clinical audits are undertaken for evaluation purposes. The findings of this study raise awareness of inconsistent ethical processes and highlight the need for expedient ethical review for clinical audits.

HIPAA's Preconsent: Impact on Study Validity

The Health Insurance Portability and Accountability Act (HIPAA) regulations added potential validity threats to clinical studies. The HIPAA regulations, using the principle of patient autonomy were designed to increase patient's control over the all health related information. The Department of Health and Human Services did not identify rules related to research regulations believing HIPAA regulations facilitate investigations through use of de-identified information. Yet, under HIPAA guidelines, health care agencies can not allow access because of the need to obtain a patient's prior permission to release raw data. The problem of how to conduct investigations in the face of the HIPAA "Privacy Rule" raises concerns for effects on subject recruitment and selection. This paper examines the impact of obtaining a HIPAA preconsent on subject recruitment, selection, and subject characteristics, and offers strategies for addressing the validity threats associated with the HIPAA regulations. J Am Psychiatr Nurses Assoc, 2008; 14(3), 225-230. DOI: 10.1177/1078390308319224.

The HIPAA authorization form and effects on survey response rates, nonresponse bias, and data quality: a randomized community study

BACKGROUND

There has been speculation that the Health Insurance Portability and Accountability Act (HIPAA) has muted participation in research but little direct evidence to substantiate those claims exists.

OBJECTIVE

To evaluate the effects of including a HIPAA authorization form (HAF) on multiple measures of survey performance. RESEARCH DESIGN, SUBJECTS: A community survey of Olmsted County, Minnesota residents conducted between September 2005 and April 2006. A total of 6939 cases were randomly assigned to 2 experimental conditions where half of the subjects received a 1-page HAF (n = 3469) and the other half did not (n = 3470).

MAIN OUTCOME MEASURES

Response rate, nonresponse bias, and data quality.

RESULTS

At the end of data collection, a response rate of 39.8% was observed in the HAF condition and 55.0% in the No HAF condition (P < 0.0001). There was a negligible but statistically significant (P < or = 0.001) over-representation of males in the No HAF condition but no difference in the amount of missing data between the 2 groups. However, reports of general health and the percentage of respondents indicating that they were nonsmokers were both significantly (P < or = 0.01) lower in the No HAF condition than in the HAF condition.

CONCLUSIONS

Inclusion of a minimally burdensome version of the HAF reduced survey response rates by up to 15 percentage points. This could have implications for a study's statistical power. There was little evidence that the form affected nonresponse bias or data quality.

Notes from the field: jumpstarting the IRB approval process in multicenter studies

OBJECTIVE

To identify strategies that facilitate readiness for local Institutional Review Board (IRB) review, in multicenter studies.

STUDY SETTING

Eleven acute care hospitals, as they applied to participate in a foundation-sponsored quality improvement collaborative.

STUDY DESIGN

Case series.

DATA COLLECTION/EXTRACTION

Participant observation, supplemented with review of written and oral communications.

PRINCIPAL FINDINGS

Applicant hospitals responded positively to efforts to engage them in early planning for the IRB review process. Strategies that were particularly effective were the provisions of application templates, a modular approach to study description, and reliance on conference calls to collectively engage prospective investigators, local IRB members, and the evaluation/national program office teams. Together, these strategies allowed early identification of problems, clarification of intent, and relatively timely completion of the local IRB review process, once hospitals were selected to participate in the learning collaborative.

CONCLUSIONS

Engaging potential collaborators in planning for IRB review may help expedite and facilitate review, without compromising the fairness of the grant-making process or the integrity of human subjects protection.

Obtaining medical records from healthcare facilities under the HIPAA Privacy Rule: the experience of a national longitudinal cohort study

The processes for acquiring medical records from healthcare facilities in longitudinal cohort studies have not been well examined post-HIPAA Privacy Rule. We examined the response rates, correlates of response rates, and response times for obtaining patient medical records from healthcare facilities under the HIPAA Privacy Rule. Medical records were requested from facilities across the country on adults 45 or older enrolled in the national longitudinal cohort study REGARDS (Reasons for Geographic and Racial Differences in Stroke) who reported physician encounters for potential stroke events. From October 2003 to October 2006, 1,439 medical records were received out of 1,518 reported eligible events (94.7%), with 39 (2.6%) requests pending at the time of the analysis. The refusal rate for record requests from healthcare facilities was only 0.4%. The median length of time to receipt of a record was 26 days (range 1-679 days). Hospitals had the fastest return time (22 days from date of request to date of receipt) compared with outpatient clinics (28 days), doctor's offices (31 days), and long-term care facilities (55 days, p < 0.01). Healthcare facilities located in the Southern region had fastest return time compared with those in the Northwestern region (23 vs. 46 days, p = 0.048). Medical records retrieval in prospective research studies is still feasible under HIPAA regulation.

Perceptions of potential donors in the Swedish public towards information and consent procedures in relation to use of human tissue samples in biobanks: a population-based study

AIMS

To assess the Swedish public's preferences for information and consent procedures when being asked for permission to use previously collected tissue samples for new research studies.

METHODS

Cross-sectional study employing postal questionnaires to a random sample of the Swedish general public (n = 6,000) in October 2002-February 2003. The response rate was 49% (n = 2,928). This paper includes only respondents who reportedly would approve of samples being taken and stored (n = 2,122).

RESULTS

When potential tissue sample donors in the general public have to strike a balance between the values at stake, i.e. the autonomy of the donor versus the research value, most (72%) prefer general consent, i.e. where consent is asked for at the outset only. They want the research ethics committee (REC) alone to decide on the use of stored samples, and they would allow storage as long as the sample is useful for research. The minority of respondents who were in favour of specific consent were more likely to be young, well educated, have negative experiences of healthcare and low trust in healthcare authorities.

CONCLUSIONS

The majority of the Swedish general public prefer general consent, and are thus willing to delegate some decisions to the RECs. However, preferences for information and consent procedures depend on the context, e.g. the risks for the donor and the purpose of the research. If feasible, procedures should be differentiated according to the preferences of individual donors, thus protecting the interests of both the minority and the majority.

Do characteristics of HIPAA consent forms affect the response rate?

OBJECTIVE

Under the The Health Insurance Portability and Accountability Act Privacy Rule, researchers are required to obtain written authorization from patients to gain access to protected health information. The purpose of this research was to examine how the characteristics of authorization forms used by hospitals affect the likelihood of consent.

METHOD

This work reports on a recent telephone survey (administered January to August 2004) of previously hospitalized patients from 16 Massachusetts hospitals. Respondents were asked to provide authorization for review of their medical records. Those respondents who agreed over the phone to be mailed authorization forms were sent a copy of their hospital's form and were asked to sign and return it. Measured characteristics of the forms included number of pages, number of fields, distinctness of institution's name, whether a witness was required, and requirement of Social Security Number (SSN).

RESULTS

We received 1021 signed forms (50.3% of all sent forms). The likelihood of return was affected by the requirement of the SSN, the clarity of the hospital name, and providing an extra copy for respondents' records. In logistic regression analysis, besides age and gender, only the SSN and clarity of the hospital name identification were significant.

CONCLUSION

Forms should be clear about the institution from which they come, easy to understand, and should not ask for SSN or other highly sensitive information unrelated to health care.

Can a chronic care model collaborative reduce heart disease risk in patients with diabetes?

BACKGROUND

There is a need to identify effective practical interventions to decrease cardiovascular disease risk in patients with diabetes.

OBJECTIVE

We examine the impact of participation in a collaborative implementing the chronic care model (CCM) on the reduction of cardiovascular disease risk in patients with diabetes.

DESIGN

Controlled pre- and postintervention study.

PATIENTS/PARTICIPANTS

Persons with diabetes receiving care at 13 health care organizations exposed to the CCM collaborative and controls receiving care in nonexposed sites.

MEASUREMENTS AND MAIN RESULTS

Ten-year risk of cardiovascular disease; determined using a modified United Kingdom Prospective Diabetes Study risk engine score. A total number of 613 patients from CCM intervention sites and 557 patients from usual care control sites met the inclusion criteria. The baseline mean 10-year risk of cardiovascular disease was 31% for both the intervention group and the control group. Participants in both groups had improved blood pressure, lipid levels, and HbA1c levels during the observation period. Random intercept hierarchical regression models showed that the intervention group had a 2.1% (95% CI -3.7%, -0.5%) greater reduction in predicted risk for future cardiovascular events when compared to the control group. This would result in a reduced risk of one cardiovascular disease event for every 48 patients exposed to the intervention.

CONCLUSIONS

Over a 1-year interval, this collaborative intervention using the CCM lowered the cardiovascular disease risk factors of patients with diabetes who were cared for in the participating organization's settings. Further work could enhance the impact of this promising multifactorial intervention on cardiovascular disease risk reduction.

Does waiver of written informed consent from the institutional review board affect response rate in a low-risk research study?

BACKGROUND

Requiring written informed consent for a minimal-risk survey may result in limited participation rates.

METHODS

Data from a cross-sectional survey of 177 older patients (87 blacks and 90 whites) with hypertension enrolled in the managed care Medicare risk product were used to assess participation rates pre- and postwaiver of written informed consent and Health Insurance Portability and Accountability Act (HIPAA) authorization. Prior to the waivers being granted, patients were contacted two times via mail with an introductory letter and an informed consent document. Those who completed and returned the informed consent document were administered the questionnaire. After 6 weeks, a waiver of written informed consent and HIPAA authorization was obtained from the Institutional Review Board. Nonparticipants were reapproached and asked to complete the questionnaire. Participation rates were recorded before and after receiving the waivers.

RESULTS

Participation rates increased from 21.5% in the prewaiver period to 57.4% in the postwaiver period (p < .001). Prewaiver participation differed by demographic subgroup and was higher among whites (26.7%) versus blacks (16.1%; p = .087), men (31.6%) versus women (16.7%; p = .024), and participants > or = 75 years old (28.4%) versus < 75 years old (14.6%; p = .025). In contrast, the postwaiver participation rate did not differ significantly across race, gender, or age subgroupings. Significant increases in participation rates from the pre- to the postwaiver time period were noted within each demographic subgroup (all p < .01).

CONCLUSIONS

We identified a substantial increase in participation rates postwaiver of written informed consent and HIPAA authorization in a minimal-risk survey. The need for written documentation for minimal-risk surveys may negatively impact recruitment of blacks, women, and patients < 75 years old.

Evaluating common de-identification heuristics for personal health information

BACKGROUND

With the growing adoption of electronic medical records, there are increasing demands for the use of this electronic clinical data in observational research. A frequent ethics board requirement for such secondary use of personal health information in observational research is that the data be de-identified. De-identification heuristics are provided in the Health Insurance Portability and Accountability Act Privacy Rule, funding agency and professional association privacy guidelines, and common practice.

OBJECTIVE

The aim of the study was to evaluate whether the re-identification risks due to record linkage are sufficiently low when following common de-identification heuristics and whether the risk is stable across sample sizes and data sets.

METHODS

Two methods were followed to construct identification data sets. Re-identification attacks were simulated on these. For each data set we varied the sample size down to 30 individuals, and for each sample size evaluated the risk of re-identification for all combinations of quasi-identifiers. The combinations of quasi-identifiers that were low risk more than 50% of the time were considered stable.

RESULTS

The identification data sets we were able to construct were the list of all physicians and the list of all lawyers registered in Ontario, using 1% sampling fractions. The quasi-identifiers of region, gender, and year of birth were found to be low risk more than 50% of the time across both data sets. The combination of gender and region was also found to be low risk more than 50% of the time. We were not able to create an identification data set for the whole population.

CONCLUSIONS

Existing Canadian federal and provincial privacy laws help explain why it is difficult to create an identification data set for the whole population. That such examples of high re-identification risk exist for mainstream professions makes a strong case for not disclosing the high-risk variables and their combinations identified here. For professional subpopulations with published membership lists, many variables often needed by researchers would have to be excluded or generalized to ensure consistently low re-identification risk. Data custodians and researchers need to consider other statistical disclosure techniques for protecting privacy.

Ureteroscopic laser papillotomy to treat papillary calcifications associated with chronic flank pain

OBJECTIVES

To evaluate retrospectively the efficacy and durability of a novel approach using ureteroscopic laser papillotomy for the treatment of painful papillary calcifications. Chronic pain due to renal papillary calcifications has not been addressed by current techniques.

METHODS

Ureteroscopic holmium laser lithotripsy and papillotomy were performed on patients with chronic pain and radiographically visible papillary calcifications without free collecting system calculi. The papillary urothelium overlying all cystic dilations and intraductal calcifications was vaporized. Treated patients answered a telephone survey to assess pain scores, duration of response, use of narcotics, and patient satisfaction. We reviewed the medical records to evaluate for procedure-related complications and serum creatinine measurements.

RESULTS

Of 20 patients who underwent laser papillotomy and responded to the telephone survey, 7 had bilateral procedures, yielding 27 renal units available for analysis. "Much less pain" was reported after 85% of the procedures, with a durable improvement reported after 59% of the procedures, at a median follow-up of 14.5 months. Significant improvements in the median pain scores were seen at 1 month (1.0, P <0.001), 6 months (2.0, P <0.001), and 1 year (1.5, P <0.001) compared with a median preoperative pain score of 9.0. The mean serum creatinine was unchanged after the procedure.

CONCLUSIONS

Ureteroscopic laser papillotomy appears to be an effective treatment option for the chronic pain associated with papillary calcifications. Laser papillotomy offers hope to patients who would otherwise have been denied an attempt at treatment because of a lack of free calculi within the collecting system.

Differences in Education, Knowledge, Self-Management Activities, and Health Outcomes for Patients With Heart Failure Cared for Under the Chronic Disease Model: The Improving Chronic Illness Care Evaluation

BACKGROUND

The objective of this study was to determine whether participation in a quality improvement (QI) collaborative for heart failure (HF) was associated with better interpersonal aspects of care and health outcomes.

METHODS AND RESULTS

We conducted a cross-sectional telephone survey of patients in 6 organizations who participated in a QI collaborative for HF (participants, n = 387) and 6 comparable control organizations (controls, n = 414) and measured provider-patient communication, education received, knowledge of HF, self-management behaviors, satisfaction, and quality of life. The participant group patients were more likely to report their doctor and nurse discussed treatment options and reviewed self-management (P < .01 for both). A total of 88% of participants were told to weigh themselves daily and record their weight compared with 34% of controls (P < .01). Participants were more likely to know how often to check their weight (P < .01), recognize symptoms of worsening HF (P < or = .01 for all), have a scale (P = .002), and monitor their weight daily (P < .001). Participants had similar quality of life but fewer emergency department visits and hospitalizations.

CONCLUSION

Participation in a QI collaborative for HF was associated with better communication, education, and knowledge, and lower health care use. Collaboratives may be a useful method for disseminating quality improvement strategies.

Psychometric properties of a new health needs analysis tool designed for cardiac patients

BACKGROUND AND OBJECTIVES

Assessing health needs is pivotal in healthcare systems, ensuring that services are appropriate for a population's genuine needs. In the absence of an appropriate investigational tool, a comprehensive process of questionnaire development was undertaken to evaluate and validate a specific health needs assessment tool for cardiac patients (Nottingham Health Needs Assessment; NHNA). Its psychometric properties were investigated in a survey of patients admitted with acute coronary syndromes.

METHOD

Two hundred and forty-two consecutive patients admitted to an acute cardiac unit with symptoms suggestive of acute myocardial infarction completed a postal questionnaire about health needs and quality-of-life, using generic (Short Form 12 and EuroQol-5D) and specific (Seattle Angina Questionnaire) health-related quality-of-life instruments.

RESULTS

Forty-six items were assigned to five domains of health-related needs according to principal component analysis, with high internal consistency (0.83-0.89). Each domain in the NHNA questionnaire correlated highly with its quality-of-life counterpart, indicating relatively high concurrent validity.

CONCLUSION

The NHNA questionnaire has acceptable psychometric features, with satisfactory construct validity as determined by quality-of-life analysis. This health needs assessment instrument appears to be a reliable means of identifying patients' needs, which is an important landmark for directing health services.

Human subjects issues and IRB review in practice-based research

PURPOSE

This article explores the challenges that practice-based research networks (PBRNs) face with respect to the regulatory requirements for institutional review board (IRB) review and the protection of human subjects in research.

METHODS

We used a regulatory and literature review, our previous research involving PBRN researchers, and our experience to identify issues in regulatory compliance and human subjects protections that present challenges to PBRNs and to suggest possible responses.

RESULTS

We identified 3 challenges that PBRNs face with respect to regulatory compliance and human subjects protections. First, ensuring compliance with federal regulations governing human subjects research across all participating practices may be difficult. Clinicians may be unfamiliar with the regulatory requirements and may not have access to an IRB that can provide the required protocol review; moreover, different IRBs may impose inconsistent requirements. Second, conducting research in the practice setting presents unique issues regarding identification of human subjects, consent, and confidentiality. Finally, the use of electronic databases across practices for research raises concerns about how to respect the wishes of participants when combining data and how to maintain confidentiality of data.

CONCLUSIONS

PBRN research makes unique contributions to the clinical evidence base by collecting data in community settings where most clinical care is provided. Such research, however, also presents unique challenges to human subject protections and regulatory compliance. Addressing these challenges is necessary to maintain public trust in and support for PBRN research. With careful planning, these ethical and regulatory challenges can be overcome.

Variations among Institutional Review Board reviews in a multisite health services research study

OBJECTIVE

To document the Institutional Review Board (IRB) review process and to explore the impact of different patient notification procedures.

DATA SOURCES/STUDY SETTING

Review of IRB application and correspondence records prospectively collected during a multisite study of health care quality involving telephone interviews of 3,000 participants across 15 primary care sites.

STUDY DESIGN

Records were reviewed to ascertain: (1) the type of IRB review conducted, (2) the number of days from submission to approval of the IRB application, (3) whether the IRB required patient notification and/or consent prior to the release of names, and (4) patient participation rates.

DATA COLLECTION/EXTRACTION METHODS

The study coordinating center prepared a common study protocol for IRB submission and assisted sites with submission. The application, correspondence with the IRB, consent script, and patient letters were collected, reviewed, coded, and analyzed.

PRINCIPAL FINDINGS

IRBs at the 15 sites and survey center varied in the type of IRB required and the number of days from submission to approval (range of 5-172 days). Four sites required patient notification in advance of the study; 2-11 percent of patients refused in opt-out sites and 37 percent in the single opt-in site. Participation among contacted patients did not appear to be related to patient notification procedures.

CONCLUSIONS

Variations in IRB requirements can affect response rates and sample generalizability.

What motivates interest in attending a familial cancer genetics clinic?

The motivation of people who seek advice about a family history of cancer was explored in a cross sectional study of new cancer referrals to five regional cancer genetics centres in England: the PACT (patient and clinical team) psychosocial study. One hundred sixty-two people took part. Measures were source of referral, estimated and perceived cancer risk, level of cancer worry, and personal and family-centred reasons for wanting to be seen in clinic. General practitioners referred more people than hospital doctors, and referred a larger proportion of people at low genetic risk of developing cancer. More than half of the participants had been the first to raise the issue of their family history of cancer. Personal motivation for referral is clearly different for those who have had a diagnosis of cancer and for those with children, compared to unaffected and childless people, and is characterised by altruistic concern for other family members rather than a perception of increased personal risk. Men and people from ethnic minorities are very significantly under-represented. Understanding people's motivation may be useful in targeting genetic counselling for people with a family history of cancer.

An evaluation of collaborative interventions to improve chronic illness care. Framework and study design

The author's dual-purpose evaluation assesses the effectiveness of formal collaboratives in stimulating organizational changes to improve chronic illness care (the chronic care model or CCM). Intervention and comparison sites are compared before and after introduction of the CCM. Multiple data sources are used to measure the degree of implementation, patient-level processes and outcomes, and organizational and team factors associated with success. Despite challenges in timely recruitment of sites and patients, data collection on 37 participating organizations, 22 control sites, and more than 4,000 patients with diabetes, congestive heart failure, asthma, or depression is nearing completion. When analyzed, these data will shed new light on the effectiveness of collaborative improvement methods and the CCM.

The requirement for prior consent to participate on survey response rates: a population-based survey in Grampian

Background

A survey was carried out in the Grampian region of Scotland with a random sample of 10,000 adults registered with a General Practitioner in Grampian. The study complied with new legislation requiring a two-stage approach to identify and recruit participants, and examined the implications of this for response rates, non-response bias and speed of response.

Methods

A two-stage survey was carried out consistent with new confidentiality guidelines. Individuals were contacted by post and asked by the Director of Public Health to consent to receive a postal or electronic questionnaire about communicating their views to the NHS. Those who consented were then sent questionnaires. Response rates at both stages were measured.

Results

25% of people returned signed consent forms and were invited to complete questionnaires. Respondents at the consent stage were more likely to be female (odds ratio (OR) response rate of women compared to men = 1.5, 95% CI 1.4, 1.7), less likely to live in deprived postal areas (OR = 0.59, 95% CI 0.45, 0.78) and more likely to be older (OR for people born in 1930–39 compared to people born in 1970–79 = 2.82, 95% CI 2.36, 3.37). 80% of people who were invited to complete questionnaires returned them. Response rates were higher among older age groups. The overall response rate to the survey was 20%, relative to the original number approached for consent (1951/10000).

Conclusion

The requirement of a separate, prior consent stage may significantly reduce overall survey response rates and necessitate the use of substantially larger initial samples for population surveys. It may also exacerbate non-response bias with respect to demographic variables.

The role of state law in protecting human subjects of public health research and practice

“Public health practice” consists of activities and Programs managed by public health agencies to promote health and prevent disease, injury, and disability. Some of these activities might be deemed to fit within the broad definition of “research” under federal regulations, known as the Common Rule, designed to protect human research subjects. The Common Rule defines research as “a systeniatic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge.” Public health activities that might under some circumstances be considered research include disease reporting, review of medical records, surveys, interviews, focus groups, specimen collection (blood, urine, etc.), and laboratory testing (both identifiable and anonymous).

There are questions about the extent to which the Common Rule applies or was intended to apply to public health practice: and it has been suggested in any case that Common Rule regulation of public health practice may not be socially optimal for both practical and principled reasons.

Applying the common rule to public health agencies: questions and tentative answers about a separate regulatory regime

No one questions the importance of protecting human subjects of research, but over the past few years dissatisfaction has surfaced with the manner in which the protection is conferred by the federal regulatory system referred to as “The Common Rule. ” Some of the criticism surfaces in print. Some bubbles out anecdotally in conversations among researchers, with complaints about the review process being virtually inevitable whenever the topic arises. Like those in other disciplines that differ more or less dramatically from the world of clinical medical research around which the Common Rule was conceptualized, public health researchers, particularly those working in official public health agencies, have experienced some tension and difficulty in adapting to the rules. The Centers For Disease Control and Prevention (CDC) has adopted guidelines that require Common Rule review for “research” but not “practice” activities.