1
|
Largent EA, Joffe S, Dickert NW, Morain SR. The ethical value of consulting community members in non-emergency trials conducted with waivers of informed consent for research. Clin Trials 2024:17407745241259360. [PMID: 38916109 DOI: 10.1177/17407745241259360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
There is growing interest in using embedded research methods, particularly pragmatic clinical trials, to address well-known evidentiary shortcomings afflicting the health care system. Reviews of pragmatic clinical trials published between 2014 and 2019 found that 8.8% were conducted with waivers of informed consent; furthermore, the number of trials where consent is not obtained is increasing with time. From a regulatory perspective, waivers of informed consent are permissible when certain conditions are met, including that the study involves no more than minimal risk, that it could not practicably be carried out without a waiver, and that waiving consent does not violate participants' rights and welfare. Nevertheless, when research is conducted with a waiver of consent, several ethical challenges arise. We must consider how to: address empirical evidence showing that patients and members of the public generally prefer prospective consent, demonstrate respect for persons using tools other than consent, promote public trust and investigator integrity, and ensure an adequate level of participant protections. In this article, we use examples drawn from real pragmatic clinical trials to argue that prospective consultation with representatives of the target study population can address, or at least mitigate, many of the ethical challenges posed by waivers of informed consent. We also consider what consultation might involve to illustrate its feasibility and address potential objections.
Collapse
Affiliation(s)
- Emily A Largent
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Neal W Dickert
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Stephanie R Morain
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
2
|
Perni S, Jimenez R, Jagsi R. Optimizing Informed Consent in Cancer Clinical Trials. Semin Radiat Oncol 2023; 33:349-357. [PMID: 37684064 DOI: 10.1016/j.semradonc.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
The concept of informed consent has evolved considerably over the course of the 20th century, leading to its establishment as a foundational ethical principle for the conduct of biomedical research in the United States. Even though it is now a highly regulated part of cancer research, the process of obtaining informed consent is often impeded by systemic, clinician, and patient factors that require both small- and large-scale intervention. New challenges and considerations continue to emerge due to innovations in clinical trial design, increases in utilization of genomic sequencing, and advances in genomic editing and artificial intelligence. We present a review of the history, policy, pragmatic challenges, and evolving role of the central ethical tenet of informed consent in clinical trials.
Collapse
Affiliation(s)
- Subha Perni
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rachel Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
| | - Reshma Jagsi
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA.
| |
Collapse
|
3
|
Snyder KL, Merz JF. A census of clinical trials conducted under the U.S. exception from informed consent rule. Acad Emerg Med 2023; 30:133-138. [PMID: 36575604 DOI: 10.1111/acem.14645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/06/2022] [Accepted: 12/19/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND The exception from informed consent (EFIC) rule was adopted in 1996, permitting waiver of informed consent for certain emergency research, including trials funded by the U.S. government. The rule requires prospective consent from patients or their legally authorized representative(s) (LAR) if practicable. For those enrolled without consent, the patient or their LAR must be given an opportunity to opt out from continued participation at the earliest opportunity. We sought to census the trials conducted under the EFIC rule to facilitate research to better understand how the rule is being used. METHODS We conducted a multipronged search to identify all trials conducted under the EFIC rule, drawing on reviews, database searches, examination of the FDA's docket, posting an inquiry on the institutional review board forum, and email requests to lead authors of all published EFIC trials and related review articles. We describe the trials, when they were started and completed, and whether they were terminated early. RESULTS We identified a total of 110 trials as of the end of April 2022: 78 complete, 13 recruiting, seven registered on clinicaltrials.gov but not yet recruiting, five trials that were abandoned before enrolling any subjects, and seven trials in early planning. Nine of the 78 completed trials were pilot or feasibility trials. Of 69 completed full trials, 30 (43.5%) were terminated early. The most common reason for early termination was futility (15 trials, 25.0%) followed by poor recruitment (10 trials, 14.5%). The rate of conduct of trials has been remarkably constant since 2001, with roughly 18 trials started in each 5-year period. CONCLUSIONS We have compiled a census of trials conducted under the U.S. FDA's EFIC rule, the availability of which we hope will stimulate further in-depth data collection and analysis of this set of trials.
Collapse
Affiliation(s)
- Krista L Snyder
- Abramson Cancer Center of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jon F Merz
- Department of Medical Ethics & Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
4
|
Dhamanaskar R, Feldman WB, Merz JF. Practicalities of Impracticability: An Interim Review of Randomized Controlled Trials. J Empir Res Hum Res Ethics 2022; 17:329-345. [PMID: 35440213 DOI: 10.1177/15562646221092663] [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: 11/17/2022]
Abstract
Impracticability is an ethical standard for waiver of informed consent in research. We examine how well the criterion of impracticability appears to have been fulfilled in a set of 36 completed randomized controlled trials (RCTs) that secured consent from some subjects or LARs and employed waivers to enroll others. These trials were identified among 155 RCTs using waivers of consent in a convenience sample drawn from 7 systematic reviews. Recruitment data were available for 19 of the 36 trials, revealing an average of 41.6% of subjects (range 0.2-98.7%, 95% CI: 24.8-58.4%) were enrolled without consent. Six trials enrolled less than 10% of subjects without consent and an overlapping set of 9 trials sought consent from all subjects or LARs at some sites while waiving consent at other sites. We question whether these trials were practicable without waivers and identify issues for consideration by investigators and ethics review boards.
Collapse
Affiliation(s)
- Roma Dhamanaskar
- Department of Health Research Methods, Evidence and Impact, 152969McMaster University Medical Centre, 1280 Main Street West, 2C Area, Hamilton, Ontario, Canada L8S 4K1
| | - William B Feldman
- Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, 1861Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120, USA
| | - Jon F Merz
- Department of Medical Ethics & Health Policy, 14640Perelman School of Medicine at the University of Pennsylvania, Blockley Hall Floor 14, 423 Guardian Drive, Philadelphia, Pennsylvania 19104-4884, USA
| |
Collapse
|
5
|
Trail K, Baptiste PJ, Hunt T, Brooks A. Conducting Research in Crisis Helpline Settings. CRISIS 2022; 43:263-269. [PMID: 35438001 DOI: 10.1027/0227-5910/a000858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Katherine Trail
- Orygen, Parkville, VIC, Australia.,Centre for Youth Mental Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, VIC, Australia
| | - Paris J Baptiste
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Tara Hunt
- Lifeline Research Foundation, Lifeline Australia, Sydney, NSW, Australia
| | - Anna Brooks
- Lifeline Research Foundation, Lifeline Australia, Sydney, NSW, Australia
| |
Collapse
|
6
|
Chen JZ, Hoang HL, Yaskina M, Kabbani D, Doucette KE, Smith SW, Lau C, Stewart J, Zurek K, Schultz M, Cervera C. Efficacy and safety of antimicrobial stewardship prospective audit and feedback in patients hospitalized with COVID-19: A protocol for a pragmatic clinical trial. PLoS One 2022; 17:e0265493. [PMID: 35320289 PMCID: PMC8942275 DOI: 10.1371/journal.pone.0265493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 03/01/2022] [Indexed: 11/19/2022] Open
Abstract
Background
The use of broad-spectrum antibiotics is widespread in patients with COVID-19 despite a low prevalence of bacterial co-infection, raising concerns for the accelerated development of antimicrobial resistance. Antimicrobial stewardship (AMS) is vital but there are limited randomized clinical trial data supporting AMS interventions such as prospective audit and feedback (PAF). High quality data to demonstrate safety and efficacy of AMS PAF in hospitalized COVID-19 patients are needed.
Methods and design
This is a prospective, multi-center, non-inferiority, pragmatic randomized clinical trial evaluating AMS PAF intervention plus standard of care (SOC) versus SOC alone. We include patients with microbiologically confirmed SARS-CoV-2 infection requiring hospital admission for severe COVID-19 pneumonia. Eligible ward beds and critical care unit beds will be randomized prior to study commencement at each participating site by computer-generated allocation sequence stratified by intensive care unit versus conventional ward in a 1:1 fashion. PAF intervention consists of real time review of antibacterial prescriptions and immediate written and verbal feedback to attending teams, performed by site-based AMS teams comprised of an AMS pharmacist and physician. The primary outcome is clinical status at post-admission day 15 measured using a 7-point ordinal scale. Patients will be followed for secondary outcomes out to 30 days. A total of 530 patients are needed to show a statistically significant non-inferiority, with 80% power and 2.5% one-sided alpha assuming standard deviation of 2 and the non-inferiority margin of 0.5.
Discussion
This study protocol presents a pragmatic clinical trial design with small unit cluster randomization for AMS intervention in hospitalized COVID-19 that will provide high-level evidence and may be adopted in other clinical situations.
Trial registration
This study is being performed at the University of Alberta and is registered at ClinicalTrials.gov (NCT04896866) on May 17, 2021.
Collapse
Affiliation(s)
- Justin Z. Chen
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
| | - Holly L. Hoang
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Maryna Yaskina
- Women and Children’s Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Dima Kabbani
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Karen E. Doucette
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Stephanie W. Smith
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Cecilia Lau
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Jackson Stewart
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Karen Zurek
- Pharmacy Services, Covenant Health, Edmonton, Alberta, Canada
| | - Morgan Schultz
- Pharmacy Services, Covenant Health, Edmonton, Alberta, Canada
| | - Carlos Cervera
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
7
|
Zhang JZ, Nicholls SG, Carroll K, Nix HP, Goldstein CE, Hey SP, Brehaut JC, McLean PC, Weijer C, Fergusson DA, Taljaard M. Informed consent in pragmatic trials: results from a survey of trials published 2014-2019. JOURNAL OF MEDICAL ETHICS 2021; 49:medethics-2021-107765. [PMID: 34782417 PMCID: PMC9107524 DOI: 10.1136/medethics-2021-107765] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 11/03/2021] [Indexed: 05/17/2023]
Abstract
OBJECTIVES To describe reporting of informed consent in pragmatic trials, justifications for waivers of consent and reporting of alternative approaches to standard written consent. To identify factors associated with (1) not reporting and (2) not obtaining consent. METHODS Survey of primary trial reports, published 2014-2019, identified using an electronic search filter for pragmatic trials implemented in MEDLINE, and registered in ClinicalTrials.gov. RESULTS Among 1988 trials, 132 (6.6%) did not include a statement about participant consent, 1691 (85.0%) reported consent had been obtained, 139 (7.0%) reported a waiver and 26 (1.3%) reported consent for one aspect (eg, data collection) but a waiver for another (eg, intervention). Of the 165 trials reporting a waiver, 76 (46.1%) provided a justification. Few (53, 2.9%) explicitly reported use of alternative approaches to consent. In multivariable logistic regression analyses, lower journal impact factor (p=0.001) and cluster randomisation (p<0.0001) were significantly associated with not reporting on consent, while trial recency, cluster randomisation, higher-income country settings, health services research and explicit labelling as pragmatic were significantly associated with not obtaining consent (all p<0.0001). DISCUSSION Not obtaining consent seems to be increasing and is associated with the use of cluster randomisation and pragmatic aims, but neither cluster randomisation nor pragmatism are currently accepted justifications for waivers of consent. Rather than considering either standard written informed consent or waivers of consent, researchers and research ethics committees could consider alternative consent approaches that may facilitate the conduct of pragmatic trials while preserving patient autonomy and the public's trust in research.
Collapse
Affiliation(s)
- Jennifer Zhe Zhang
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Hayden Peter Nix
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Cory E Goldstein
- Philosophy, Rotman Institute of Philosophy, London, Ontario, Canada
| | | | - Jamie C Brehaut
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Charles Weijer
- Medicine, Epidemiology and Biostatistics, and Philosophy, Western University, London, Ontario, Canada
| | - Dean A Fergusson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
8
|
Nix HP, Weijer C, Brehaut JC, Forster D, Goldstein CE, Taljaard M. Informed consent in cluster randomised trials: a guide for the perplexed. BMJ Open 2021; 11:e054213. [PMID: 34580104 PMCID: PMC8477335 DOI: 10.1136/bmjopen-2021-054213] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/15/2021] [Indexed: 11/19/2022] Open
Abstract
In a cluster randomised trial (CRT), intact groups-such as communities, clinics or schools-are randomised to the study intervention or control conditions. The issue of informed consent in CRTs has been particularly challenging for researchers and research ethics committees. Some argue that cluster randomisation is a reason not to seek informed consent from research participants. In fact, systematic reviews have found that, relative to individually randomised trials, CRTs are associated with an increased likelihood of inadequate reporting of consent procedures and inappropriate use of waivers of consent. The objective of this paper is to clarify this confusion by providing a practical and useful framework to guide researchers and research ethics committees through consent issues in CRTs. In CRTs, it is the unit of intervention-not the unit of randomisation-that drives informed consent issues. We explicate a three-step framework for thinking through informed consent in CRTs: (1) identify research participants, (2) identify the study element(s) to which research participants are exposed, and (3) determine if a waiver of consent is appropriate for each study element. We then apply our framework to examples of CRTs of cluster-level, professional-level and individual-level interventions, and provide key lessons on informed consent for each type of CRT.
Collapse
Affiliation(s)
- Hayden P Nix
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Charles Weijer
- Department of Philosophy, Western University, London, Ontario, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
- Department of Medicine, Western University, London, Ontario, Canada
| | - Jamie C Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - David Forster
- Institutional Review Board, WIRB-Copernicus Group Inc, Puyallup, Washington, USA
| | - Cory E Goldstein
- Department of Philosophy, Western University, London, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
9
|
Lin LY, Jochym N, Merz JF. Refusal rates and waivers of informed consent in pragmatic and comparative effectiveness RCTs: A systematic review. Contemp Clin Trials 2021; 104:106361. [PMID: 33737197 DOI: 10.1016/j.cct.2021.106361] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 03/12/2021] [Accepted: 03/12/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pragmatic and comparative effectiveness randomized controlled trials (RCTs) aim to be highly generalizable studies, with broad applicability and flexibility in methods. These trials also address recruitment issues by minimizing exclusions. The trials may also appeal to potential subjects because of lower risk and lower burdens of participation. We sought to examine rates of refusal and uses of waivers of informed consent in pragmatic and comparative effectiveness RCTs. METHODS A systematic review of pragmatic and comparative effectiveness RCTs performed wholely or in part in the United States and first published in 2014 and 2017. RESULTS 103 studies involving 105 discrete populations were included for review. Refusal data was collected for 71 RCTs. Overall, studies reported an average rate of 31.9% of potential subjects refused participation; on an individual basis, 38.4% of people asked to take part refused at some point during recruitment. 23 trials (22%) were performed, at least in part, with a waiver of informed consent, 7 (30%) of which provided any form of notice to subjects. CONCLUSIONS Overall refusal rates for pragmatic and comparative effectiveness RCTs appear roughly the same as other types of research, with studies reporting about a third of people solicited for participation refuse. Moreover, informed consent was waived in 22% (95% Binomial exact Confidence Interval 13.9-30.5%) of the trials, and further study is needed to understand when waivers are justified and when notice should be provided.
Collapse
Affiliation(s)
- Lisa Y Lin
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, United States of America.
| | - Nicole Jochym
- Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ 08103, United States of America
| | - Jon F Merz
- Department of Medical Ethics & Health Policy, Perelman School of Medicine at the University of Pennsylvania, Blockley Hall 1427, 423 Guardian Drive, Philadelphia, PA 19104-4884, United States of America.
| |
Collapse
|