Variations in institutional review board decisions for HIV quality of care studies: a potential source of study bias

Use of single IRBs for multi-site studies: A case report and commentary from a National Drug Abuse Treatment Clinical Trials Network study

Recent NIH policy stipulates that multi-site studies must use a single or IRB (Institutional Review Board) in order to streamline the review process while maintaining standards for human subjects protection. The Western States Node of the Clinical Trials Network (CTN) used a single IRB for protocol CTN-0067, a clinical trial testing the use of an opioid antagonist (extended-release naltrexone) versus opioid agonists (buprenorphine or methadone) for opioid use disorders among individuals living with HIV. This case study discusses the processes and challenges associated with use of a single IRB. These lessons are also informed by other single IRB experiences within the CTN. The intention of the NIH single IRB policy is to facilitate efficient IRB processes. Advanced planning and transparent communication, however, are critical to avoid stalling IRB approval and protocol implementation. Research teams need to account for local IRB willingness to cede to a single IRB and understand the variations in interpretations of abbreviated reviews. In order to facilitate the effective use of single IRBs, recommendations include assigning staff at each study site for IRB submission coordination and interaction with the lead site IRB staff, training investigators and key regulatory staff on expectations for working with single IRBs, dedicating a regulatory specialist at the lead site to manage the process, developing a communication plan, and supporting the development of strong working relationships with local regulatory staff and the single IRB. The CTN experiences with single IRBs may provide insights for other investigators.

Costs and benefits of the national cancer institute central institutional review board

PURPOSE

In 2001, the National Cancer Institute (NCI) formed the Central Institutional Review Board (CIRB) to conduct a single human subjects review for its multisite phase III oncology trials. The goal of this study was to assess whether NCI's CIRB was associated with lower effort, time, and cost in processing adult phase III oncology trials.

METHODS

We conducted an observational study and compared sites affiliated with the NCI CIRB to unaffiliated sites that used their local IRB for review. Oncology research staff and IRB staff were surveyed to understand effort and timing. Response rates were 60% and 42%, respectively. Analysis of these survey data yielded information on effort, timing, and costs. We combined these data with CIRB operational data to determine the net savings of the CIRB using a societal perspective.

RESULTS

CIRB affiliation was associated with faster reviews (33.9 calendar days faster on average), and 6.1 fewer hours of research staff effort. CIRB affiliation was associated with a savings of $717 per initial review. The estimated cost of running the CIRB was $161,000 per month. The CIRB yielded a net cost of approximately $55,000 per month from a societal perspective. Whether the CIRB results in higher or lower quality reviews was not assessed because there is no standard definition of review quality.

CONCLUSION

The CIRB was associated with decreases in investigator and IRB staff effort and faster protocol reviews, although savings would be higher if institutions used the CIRB as intended.

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.

Institutional variability in a minimal risk, population-based study: recognizing policy barriers to health services research

OBJECTIVE

To describe (1) the institutional variability in study approval and willingness to obtain federal assurance documents for a federally supported, minimal risk health services research project conducted during the implementation of the Privacy Rule and federalwide assurances, and (2) the potential impact of such policy on selection of research subjects and generalizability of study results.

DATA SOURCES

Primary data collection from 2001 to 2004.

STUDY DESIGN

We provide a descriptive analysis of a prospective, observational, out-of-hospital study.

STUDY SETTING

Twenty-seven pediatric receiving hospitals were approached for participation in a study validating a decision rule to identify seriously injured children involved in motor vehicle crashes in Los Angeles County. Two federal research policies, the Privacy Rule and the requirement for federalwide assurances, were implemented during the project.

DATA COLLECTION

All 27 hospitals were sent an identical research protocol requesting approval to review charts of children transported to their facility. The research protocol included strict confidentiality protections, was noninterventional, did not alter the standard of care at the scene or at the hospital, and met requirements for waivers of both informed consent and the Health Insurance Portability and Accountability Act. Because the project was federally supported, all participating hospitals were required to have a federalwide assurance. The hospitals receiving the research protocol were the unit of analysis and outcomes included: approval of the research protocol, total number of days to study approval, and successfully obtaining a federalwide assurance.

PRINCIPLE FINDINGS

Overall, 6 of 27 (22 percent) hospitals refused to participate in the study, all of which were community hospitals. The median time from submitting an application to study approval was 118 days (interquartile range 34-254, range 12-960 days) and time to study approval differed when hospitals were categorized by type and the presence of an institutional review board (p=.053). No institutional review resulted in a change in the basic study protocol, although one hospital required paramedic consent. Following intensive efforts to secure federalwide assurances, 12 of 27 hospitals (44 percent) possessed the necessary assurance to conduct the study. If all patients transported to hospitals that failed to obtain such an assurance were omitted, the sample size would have been reduced by 62 percent and would have excluded all children transported to community hospitals.

CONCLUSIONS

There is substantial institutional variability in approval of a minimal risk observational study and in willingness to obtain a federalwide assurance, particularly among community hospitals. Federal research policy involving patient privacy and institutional assurances may be contributing to this variability, which can adversely affect selection of research subjects, disrupt population-based study design, and threaten the generalizability of study results.

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.

HIV-related Pneumocystis carinii pneumonia in older patients hospitalized in the early HAART era

OBJECTIVE

To determine whether older age continues to influence patterns of care and in-hospital mortality for hospitalized persons with HIV-related Pneumocystis carinii pneumonia (PCP), as determined in our prior study from the 1980s.

DESIGN

Retrospective chart review.

PATIENTS/SETTING

Patients (1,861) with HIV-related PCP at 78 hospitals in 8 cities from 1995 to 1997.

MEASUREMENTS

Medical record notation of possible HIV infection; alveolar-arterial oxygen gradient; CD4 lymphocyte count; presence or absence of wasting; timely use of anti-PCP medications; in-hospital mortality.

MAIN RESULTS

Compared to younger patients, patients > or =50 years of age were less likely to have HIV mentioned in their progress notes (70% vs 82%, P <.001), have mild or moderately severe PCP cases at admission (89% vs 96%, P <.002), receive anti-PCP medications within the first 2 days of hospitalization (86% vs 93%, P <.002), and survive hospitalization (82% vs 90%, P <.003). However, age was not a significant predictor of mortality after adjustment for severity of PCP and timeliness of therapy.

CONCLUSIONS

While inpatient PCP mortality has improved by 50% in the past decade, 2-fold age-related mortality differences persist. As in the 1980s, these differences are associated with lower rates of recognition of HIV, increased severity of illness at admission, and delays in initiation of PCP-specific treatments among older individuals--factors suggestive of delayed recognition of HIV infection, pneumonia, and PCP, respectively. Continued vigilance for the possibility of HIV and HIV-related PCP among persons > or =50 years of age who present with new pulmonary symptoms should be encouraged.