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Brenna CTA, Walton N, Cohn M, Siddiqui U, Huszti E, Brull R. Coerced consent in clinical research: study protocol for a randomized controlled trial. Trials 2024; 25:452. [PMID: 38965542 PMCID: PMC11223386 DOI: 10.1186/s13063-024-08294-4] [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: 02/06/2024] [Accepted: 06/21/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Despite the low-risk nature of participation in most clinical anesthesia trials, subject recruitment on the same day as surgery is often restricted due to the concerns of researchers and local research ethics boards that same-day consent may not afford adequate time and opportunity for patients to weigh and make decisions, as well as perceptions of patient vulnerability immediately prior to surgery that could impact the voluntary nature and the rigor of the informed consent process. However, specialties such as anesthesiology, critical care, interventional radiology, and emergency medicine have a varied pattern of practice and patient acquaintance that does not typically afford the luxury of time or, in many cases, advance consent for participation in research. Indeed, the initial encounter between anesthesiologists and patients undergoing elective procedures routinely occurs on the day of surgery. Concerns of coercion related to same-day consent for clinical anesthesia research trials have not been borne out in the literature, and represent a significant obstacle to clinical researchers, as well as to the patients who are denied opportunities for potential benefit through participation in research studies. METHODS We describe the protocol for a prospective randomized controlled trial examining the voluntariness of patient consent, solicited either in advance of surgery or on the same day, to participate in an anesthesia research study at Women's College Hospital. One hundred fourteen patients scheduled to undergo ambulatory anterior cruciate ligament repair facilitated by general anesthesia with an adductor canal block will be randomized for recruitment either (a) in the pre-operative assessment clinic before the day of surgery or (b) on the day of surgery, to be approached for consent to participate in a fabricated research study of adjunct medications in adductor canal blocks. Regardless of allocation, patients in both groups will receive the same routine standard of care and will complete a post-operative questionnaire to signal perceptions of undue influence in the process of providing informed consent for the fabricated trial. DISCUSSION This study will inform trial design and practice guidelines surrounding the amount of time patients ought to be afforded in order to make durable decisions to participate (or not) in clinical research studies. This is expected to impact trial recruitment in a variety of clinical settings where researchers have only brief opportunities to interface with patients. TRIAL REGISTRATION The trial was registered prospectively on the Open Science Framework (OSF), registration #46twc, on 2023-Mar-17.
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Affiliation(s)
- Connor T A Brenna
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Physiology, University of Toronto, Toronto, ON, Canada.
| | - Nancy Walton
- Yeates School of Graduate Studies, Toronto Metropolitan University, Toronto, ON, Canada
| | - Melanie Cohn
- Krembil Brain Institute, University Health Network, Toronto, ON, Canada
| | - Urooj Siddiqui
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Department, University Health Network, Toronto, ON, Canada
| | - Richard Brull
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada.
- Department of Anesthesia, Women's College Hospital, Toronto, ON, Canada.
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Tokita HK, Assel M, Serafin J, Lin E, Sarraf L, Masson G, Moo TA, Nelson JA, Simon BA, Vickers AJ. Optimizing accrual to a large-scale, clinically integrated randomized trial in anesthesiology: A 2-year analysis of recruitment. Clin Trials 2024:17407745241255087. [PMID: 38895970 DOI: 10.1177/17407745241255087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
BACKGROUND Performing large randomized trials in anesthesiology is often challenging and costly. The clinically integrated randomized trial is characterized by simplified logistics embedded into routine clinical practice, enabling ease and efficiency of recruitment, offering an opportunity for clinicians to conduct large, high-quality randomized trials under low cost. Our aims were to (1) demonstrate the feasibility of the clinically integrated trial design in a high-volume anesthesiology practice and (2) assess whether trial quality improvement interventions led to more balanced accrual among study arms and improved trial compliance over time. METHODS This is an interim analysis of recruitment to a cluster-randomized trial investigating three nerve block approaches for mastectomy with immediate implant-based reconstruction: paravertebral block (arm 1), paravertebral plus interpectoral plane blocks (arm 2), and serratus anterior plane plus interpectoral plane blocks (arm 3). We monitored accrual and consent rates, clinician compliance with the randomized treatment, and availability of outcome data. Assessment after the initial year of implementation showed a slight imbalance in study arms suggesting areas for improvement in trial compliance. Specific improvement interventions included increasing the frequency of communication with the consenting staff and providing direct feedback to clinician investigators about their individual recruitment patterns. We assessed overall accrual rates and tested for differences in accrual, consent, and compliance rates pre- and post-improvement interventions. RESULTS Overall recruitment was extremely high, accruing close to 90% of the eligible population. In the pre-intervention period, there was evidence of bias in the proportion of patients being accrued and receiving the monthly block, with higher rates in arm 3 (90%) compared to arms 1 (81%) and 2 (79%, p = 0.021). In contrast, in the post-intervention period, there was no statistically significant difference between groups (p = 0.8). Eligible for randomization rate increased from 89% in the pre-intervention period to 95% in the post-intervention period (difference 5.7%; 95% confidence interval = 2.2%-9.4%, p = 0.002). Consent rate increased from 95% to 98% (difference of 3.7%; 95% confidence interval = 1.1%-6.3%; p = 0.004). Compliance with the randomized nerve block approach was maintained at close to 100% and availability of primary outcome data was 100%. CONCLUSION The clinically integrated randomized trial design enables rapid trial accrual with a high participant compliance rate in a high-volume anesthesiology practice. Continuous monitoring of accrual, consent, and compliance rates is necessary to maintain and improve trial conduct and reduce potential biases. This trial methodology serves as a template for the implementation of other large, low-cost randomized trials in anesthesiology.
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Affiliation(s)
- Hanae K Tokita
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa Assel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joanna Serafin
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emily Lin
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Leslie Sarraf
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Geema Masson
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tracy-Ann Moo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonas A Nelson
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brett A Simon
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Tilch MK, Schranz M, Moringlane A, Theobald M, Hess G. Struggling with extensive informed consent procedures for cancer trials-is there even a benefit for the patients? Support Care Cancer 2022; 30:6593-6602. [PMID: 35486229 PMCID: PMC9213264 DOI: 10.1007/s00520-022-07063-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/11/2022] [Indexed: 11/28/2022]
Abstract
Purpose Informed consent procedures in clinical trials often differ in length and complexity to those in clinical routine care. Little is known about the benefit of extensive procedures as intended in clinical trials compared to procedures in routine cancer treatment. Methods In two different clinical studies performed at a comprehensive cancer center, we compared patients’ comprehension and satisfaction of current informed consent procedures in routine clinical care with the level of comprehension and satisfaction of patients treated within clinical trials. Patients with a new cancer diagnosis and recent informed consent received a questionnaire about satisfaction, comprehension, time management, and physician–patient relationship of the informed consent process. Patients in cohort 1 consented to cancer treatment within a clinical trial and were additionally interviewed in a structured way; patients in cohort 2 consented to “standard” chemotherapy and received a follow-up questionnaire after 6 months. Results In cohort 1, 82 patients completed the questionnaire and had an additional structured interview. They were treated in 41 different trials, receiving up to 40 pages of educational material. In cohort 2, 89 patients completed the first and 52 completed the follow-up questionnaire after receiving a standard informed consent form of 6 pages. Subjective understanding and satisfaction with the information provided was equally very high. However, deficits in objective understanding were observed in both cohorts. Conclusion Extensive informed consent procedures for clinical cancer trials have not been associated with a higher level of satisfaction or measurable objective understanding; therefore, the benefit seems to be limited.
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Affiliation(s)
- Marie-Kristin Tilch
- Department of Hematology, Oncology and Pneumology & University Cancer Center, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Melanie Schranz
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | | | - Matthias Theobald
- Department of Hematology, Oncology and Pneumology & University Cancer Center, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Georg Hess
- Department of Hematology, Oncology and Pneumology & University Cancer Center, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany.
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Schwaegermann MK, Schranz M, Moehler M, Labenz C, Moringlane A, Schmidt M, Theobald M, Hess G. Any progress in informed consenting for cancer treatment? Results from a cross sectional analysis at a comprehensive cancer center. J Cancer Res Clin Oncol 2021; 147:2117-2126. [PMID: 33420813 PMCID: PMC8164598 DOI: 10.1007/s00432-020-03495-1] [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] [Received: 08/05/2020] [Accepted: 12/02/2020] [Indexed: 11/30/2022]
Abstract
Purpose Informed consent is required prior to any medical procedure. In the context of cancer treatment, special efforts are needed to inform cancer patients properly about treatment, potential sequelae and alternative therapies. Little is known about the effectiveness of current informed consent strategies and patients’ individual satisfaction. Given the heterogeneity in terms of age, education, sex and other factors, detailed understanding of patients’ comprehension and perception is the basis for further optimization of the informed consent process, which was the aim of the current investigation. Methods Patients with a new cancer diagnosis and recent informed consent were asked to complete a questionnaire about satisfaction, comprehension, time management, physician–patient relationship and other items of the informed consent process. Patients were followed for 6 months and invited to complete a follow-up questionnaire. Results In total, 89 patients completed the first questionnaire and 52 the follow-up questionnaire. Subjective understanding was assumed high, however, this did not correlate with objective understanding. Age and education were identified as influencing factors for comprehension. 85% of the patients were satisfied with the information provided. A major gap was the information on alternative therapies. Moreover, not all patients perceived the consent dialog as such, and particularly the individual treatment intention partially remained unclear for some patients. Conclusions To ensure that informed consent is based on solid understanding, informed consenting must be patient-centered and consider the individual expectations, needs and abilities of cancer patients. Further studies are required to develop tailored informed consent strategies.
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Affiliation(s)
- Marie-Kristin Schwaegermann
- Department of Internal Medicine III, Comprehensive Cancer Center, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Melanie Schranz
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Markus Moehler
- Department of Internal Medicine I, Comprehensive Cancer Center, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine I, Comprehensive Cancer Center, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Alice Moringlane
- Department of Internal Medicine III, Comprehensive Cancer Center, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Marcus Schmidt
- Department of Gynecology, Comprehensive Cancer Center, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Matthias Theobald
- Department of Internal Medicine III, Comprehensive Cancer Center, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Georg Hess
- Department of Internal Medicine III, Comprehensive Cancer Center, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
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Siddiqui U, Hawryluck L, Muneeb Ahmed M, Brull R. Same-Day Consent for Regional Anesthesia Clinical Research Trials: It's About Time. Anesth Analg 2020; 131:1657-1662. [PMID: 32796158 PMCID: PMC7469595 DOI: 10.1213/ane.0000000000005196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Laura Hawryluck
- Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad Muneeb Ahmed
- Faculty of Health Sciences, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Richard Brull
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, Ontario, Canada
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Zdravkovic M, Kamenik M. A prospective randomized controlled study of combined spinal-general anesthesia vs. general anesthesia for laparoscopic gynecological surgery: Opioid sparing properties. J Clin Anesth 2020; 64:109808. [PMID: 32305787 DOI: 10.1016/j.jclinane.2020.109808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/20/2020] [Accepted: 04/04/2020] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVE We aimed to determine the magnitude of peri-operative opioid sparing effect when general anesthesia is combined with spinal analgesia for laparoscopic gynecological surgery. DESIGN A prospective randomized controlled study; a three-group trial with two comparisons (each intervention group to control). SETTING Operating room and postoperative recovery area. PATIENTS Patients aged between 18 and 65 years with American Society of Anesthesiologists physical status 1 or 2 who were scheduled for inpatient elective laparoscopic gynecological surgery with expected pneumoperitoneum duration of at least 20 min. Of 102 randomized patients, 99 completed the study. INTERVENTIONS Patients were randomized to general anesthesia alone (control group) or combined with very-low-dose (levobupivacaine 3.75 mg; sufentanil 2.5 μg) or low-dose (levobupivacaine 7.5 mg; sufentanil 2.5 μg) spinal analgesia. MEASUREMENTS Primary endpoints were perioperative opioid consumption and pain scores (11-point numeric rating scale) at 30 min, 1 h, 2 h, 4 h and 24 h post-surgery. Secondary endpoints were patient satisfaction with anesthetic care and participation in research, sevoflurane consumption and adverse effects. MAIN RESULTS Intra-operative sufentanil (median [95% CI]) consumption was 16.1 (10.5-22.6) μg/h in the control group versus 4.7 (3.2-9.2) μg/h in the very-low-dose and versus 2.9 (0.0-4.0) μg/h in the low-dose spinal analgesia groups (p < 0.001, for both comparisons). Median (95% CI) piritramide consumption at 24 h post-surgery was 7.5 (3-8) mg in the control group versus 5 (0-7.5) mg in the very-low dose spinal analgesia group (p = 0.182) and versus 2 (0-2.5) mg in the low-dose spinal analgesia group (p = 0.001). Postoperative pain scores were consistently <3 only in the low dose spinal analgesia group. Patient satisfaction with anesthetic care and participation in research was very high in all groups. CONCLUSIONS Low-dose spinal analgesia in combination with general anesthesia reduces peri-operative opioid consumption in laparoscopic gynecological surgery in immediate postoperative period.
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Affiliation(s)
- Marko Zdravkovic
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia; Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia.
| | - Mirt Kamenik
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia; Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia
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Innovation in Clinical Research Regulation. Anesthesiology 2019; 132:1-4. [PMID: 31789636 DOI: 10.1097/aln.0000000000003026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Oh JH, Shin WJ, Park S, Kim KH. Does preoperative anxiety felt by patients requested to participate in clinical trials related to general anesthesia before elective surgery depend on temperament? Korean J Anesthesiol 2017; 70:277-291. [PMID: 28580078 PMCID: PMC5453889 DOI: 10.4097/kjae.2017.70.3.277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 02/07/2017] [Accepted: 02/16/2017] [Indexed: 12/04/2022] Open
Abstract
Background Preoperative anxiety may differ according to patient temperament. It will be increased when patients are requested to participate in a study involving anesthesia. The purpose of this study was to show that the anxiety felt when patients are requested to participate may differ according to temperament in both patients who agree and disagree to participate. Methods Three hundred and twenty-one patients over age 18 with American Society of Anesthesiologists 1 and 2 completed a survey questionnaire. The degree of anxiety was measured according to patient temperament. It was compared on the basis of the State-Trait Anxiety Inventory (STAI) and visual analogue scale (VAS). Results In the agreed group, the degree of anxiety measured by “usual, present STAI” and VAS in the monitors (those who want to know as much as possible about anesthesia and surgery) was significantly higher than that in the blunters (those who want to know as little as possible) (P = 0.041 for the “usual STAI”, 0.017 for “present STAI”, and 0.001 for VAS, respectively). Among patients with a lower educational level, the numbers of blunters and monitors were 57 (79%) and 32 (59%), respectively, indicating that the ratio of blunters was significantly higher (P = 0.026). Conclusions Both traits of patients in each group were influenced by psychological burdens. The anxiety of the monitors who agreed to participate was significantly higher than that of blunters. In addition to temperament, education level affects participation. Obtaining consent for participation by understanding temperament and considering factors that may reduce the participation rate will be required.
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Affiliation(s)
- Jae Hoon Oh
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Woo Jong Shin
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Suin Park
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Kyoung Hun Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University College of Medicine, Seoul, Korea
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