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Meierer K, Borry P, Sanchini V. Appropriate inclusion of adult research participants with intellectual disability: an in-depth review of guidelines and policy statements. Account Res 2024; 31:259-280. [PMID: 36031953 DOI: 10.1080/08989621.2022.2119136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
The history of human-subject experimentation has shown the need for safeguards to protect participants from abuse. Balancing participant protection with adequate representation of the adult intellectual disability population in research presents an important challenge. Our study aimed to analyze guidance on the appropriate inclusion of adults with intellectual disability who are or are not able to consent to biomedical research participation. Terminology, consent and type of ethically acceptable research provisions relevant to adult participants with intellectual disability were comprehensively reviewed in a selection of 17 international and national ethical research guidelines and statements. Most guidelines and statements recommend that adult participants with intellectual disability who are unable to consent be included when it is not possible to conduct the same research with adults capable of independent decision-making, or when there is therapeutic benefit and only minimal risk. Instead of naming specific requirements, the Australian statement stands out by asserting the "individual right" to participate. Assent requirements for incapacitated adults are not explicitly mentioned in most documents reviewed. There appears to be room for further description of the importance of careful capacity assessments and solid assent requirements in ethical research guidance documentation to promote meaningful participation of adults with intellectual disability.
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Affiliation(s)
- Klara Meierer
- Faculty of Medicine and Health Sciences, Department of Psychiatry, McGill University, Montreal Quebec, Canada
| | - Pascal Borry
- Department of Public Health and Primary Care, Center for Biomedical Ethics and Law, Leuven, Belgium
| | - Virginia Sanchini
- Department of Public Health and Primary Care, Center for Biomedical Ethics and Law, Leuven, Belgium
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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2
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Verkerk K, Voest EE. Generating and using real-world data: A worthwhile uphill battle. Cell 2024; 187:1636-1650. [PMID: 38552611 DOI: 10.1016/j.cell.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/04/2024] [Accepted: 02/09/2024] [Indexed: 04/02/2024]
Abstract
The precision oncology paradigm challenges the feasibility and data generalizability of traditional clinical trials. Consequently, an unmet need exists for practical approaches to test many subgroups, evaluate real-world drug value, and gather comprehensive, accessible datasets to validate novel biomarkers. Real-world data (RWD) are increasingly recognized to have the potential to fill this gap in research methodology. Established applications of RWD include informing disease epidemiology, pharmacovigilance, and healthcare quality assessment. Currently, concerns regarding RWD quality and comprehensiveness, privacy, and biases hamper their broader application. Nonetheless, RWD may play a pivotal role in supplementing clinical trials, enabling conditional reimbursement and accelerated drug access, and innovating trial conduct. Moreover, purpose-built RWD repositories may support the extension or refinement of drug indications and facilitate the discovery and validation of new biomarkers. This perspective explores the potential of leveraging RWD to advance oncology, highlights its benefits and challenges, and suggests a path forward in this evolving field.
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Affiliation(s)
- K Verkerk
- Department of Molecular Oncology & Immunology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Oncode Institute, Utrecht, the Netherlands
| | - E E Voest
- Department of Molecular Oncology & Immunology, The Netherlands Cancer Institute, Amsterdam, the Netherlands; Oncode Institute, Utrecht, the Netherlands; Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam 1066 CX, the Netherlands.
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3
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Hershfeld B, Klein B, White PB, Mont MA, Bitterman AD. Informed Consent in Orthopaedic Surgery: A Primer. J Bone Joint Surg Am 2024; 106:472-476. [PMID: 38190442 DOI: 10.2106/jbjs.23.00316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Affiliation(s)
- Benjamin Hershfeld
- College of Osteopathic Medicine, New York Institute of Technology, Glen Head, New York
| | | | | | - Michael A Mont
- Northwell Orthopedics, New Hyde Park, New York
- Department of Orthopaedic Surgery, Sinai Hospital, Baltimore, Maryland
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4
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Leviton A, Loddenkemper T. Design, implementation, and inferential issues associated with clinical trials that rely on data in electronic medical records: a narrative review. BMC Med Res Methodol 2023; 23:271. [PMID: 37974111 PMCID: PMC10652539 DOI: 10.1186/s12874-023-02102-4] [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: 10/17/2022] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
Real world evidence is now accepted by authorities charged with assessing the benefits and harms of new therapies. Clinical trials based on real world evidence are much less expensive than randomized clinical trials that do not rely on "real world evidence" such as contained in electronic health records (EHR). Consequently, we can expect an increase in the number of reports of these types of trials, which we identify here as 'EHR-sourced trials.' 'In this selected literature review, we discuss the various designs and the ethical issues they raise. EHR-sourced trials have the potential to improve/increase common data elements and other aspects of the EHR and related systems. Caution is advised, however, in drawing causal inferences about the relationships among EHR variables. Nevertheless, we anticipate that EHR-CTs will play a central role in answering research and regulatory questions.
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Affiliation(s)
- Alan Leviton
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Tobias Loddenkemper
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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5
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Goldstein CE, van der Graaf R. Simplified consent in cluster randomised trials: the new EU Clinical Trials Regulation does not provide sufficient guidance. BMJ 2023; 382:e075773. [PMID: 37704224 DOI: 10.1136/bmj-2023-075773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Affiliation(s)
- Cory E Goldstein
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute, Ottawa ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa ON, Canada
| | - Rieke van der Graaf
- Julius Center, Department of Bioethics and Health Humanities, University Medical Center Utrecht, Netherlands
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6
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Casey JD, Beskow LM, Brown J, Brown SM, Gayat É, Ng Gong M, Harhay MO, Jaber S, Jentzer JC, Laterre PF, Marshall JC, Matthay MA, Rice TW, Rosenberg Y, Turnbull AE, Ware LB, Self WH, Mebazaa A, Collins SP. Use of pragmatic and explanatory trial designs in acute care research: lessons from COVID-19. THE LANCET. RESPIRATORY MEDICINE 2022; 10:700-714. [PMID: 35709825 PMCID: PMC9191864 DOI: 10.1016/s2213-2600(22)00044-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/21/2021] [Accepted: 01/20/2022] [Indexed: 12/15/2022]
Abstract
Unique challenges arise when conducting trials to evaluate therapies already in common clinical use, including difficulty enrolling patients owing to widespread open-label use of trial therapies and the need for large sample sizes to detect small but clinically meaningful treatment effects. Despite numerous successes in trials evaluating novel interventions such as vaccines, traditional explanatory trials have struggled to provide definitive answers to time-sensitive questions for acutely ill patients with COVID-19. Pragmatic trials, which can increase efficiency by allowing some or all trial procedures to be embedded into clinical care, are increasingly proposed as a means to evaluate therapies that are in common clinical use. In this Personal View, we use two concurrently conducted COVID-19 trials of hydroxychloroquine (the US ORCHID trial and the UK RECOVERY trial) to contrast the effects of explanatory and pragmatic trial designs on trial conduct, trial results, and the care of patients managed outside of clinical trials. In view of the potential advantages and disadvantages of explanatory and pragmatic trial designs, we make recommendations for their optimal use in the evaluation of therapies in the acute care setting.
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Affiliation(s)
- Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Laura M Beskow
- Vanderbilt Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeremy Brown
- Office of Emergency Care Research, National Institute of Neurological Disorders and Stroke, Division of Clinical Research, National Institutes of Health, Bethesda, MD, USA
| | - Samuel M Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and University of Utah, Salt Lake City, UT, USA
| | - Étienne Gayat
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; INSERM UMR-S 942, MASCOT, Université Paris Cité, Paris, France
| | - Michelle Ng Gong
- Division of Critical Care Medicine and Division of Pulmonary Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Michael O Harhay
- Palliative and Advanced Illness Research (PAIR) Center Clinical Trials Methods and Outcomes Lab, and Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Samir Jaber
- Saint Eloi Intensive Care Unit, Montpellier University Hospital, and PhyMedExp, INSERM, CNRS, Université de Montpellier, Montpellier, France
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Pierre-François Laterre
- Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain, Brussels, Belgium
| | - John C Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France; INSERM UMR-S 942, MASCOT, Université Paris Cité, Paris, France
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education,and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Federico CA, Heagerty PJ, Lantos J, O'Rourke P, Rahimzadeh V, Sugarman J, Weinfurt K, Wendler D, Wilfond BS, Magnus D. Ethical and epistemic issues in the design and conduct of pragmatic stepped-wedge cluster randomized clinical trials. Contemp Clin Trials 2022; 115:106703. [PMID: 35176501 PMCID: PMC9272561 DOI: 10.1016/j.cct.2022.106703] [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: 10/01/2021] [Revised: 01/27/2022] [Accepted: 02/02/2022] [Indexed: 11/27/2022]
Abstract
Stepped-wedge cluster randomized trial (SW-CRT) designs are increasingly employed in pragmatic research; they differ from traditional parallel cluster randomized trials in which an intervention is delivered to a subset of clusters, but not to all. In a SW-CRT, all clusters receive the intervention under investigation by the end of the study. This approach is thought to avoid ethical concerns about the denial of a desired intervention to participants in control groups. Such concerns have been cited in the literature as a primary motivation for choosing SW-CRT design, however SW-CRTs raise additional ethical concerns related to the delayed implementation of an intervention and consent. Yet, PCT investigators may choose SW-CRT designs simply because they are concerned that other study designs are infeasible. In this paper, we examine justifications for the use of SW-CRT study design, over other designs, by drawing on the experience of the National Institutes of Health's Health Care Systems Research Collaboratory (NIH Collaboratory) with five pragmatic SW-CRTs. We found that decisions to use SW-CRT design were justified by practical and epistemic reasons rather than ethical ones. These include concerns about feasibility, the heterogeneity of cluster characteristics, and the desire for simultaneous clinical evaluation and implementation. In this paper we compare the potential benefits of SW-CRTs against the ethical and epistemic challenges brought forth by the design and suggest that the choice of SW-CRT design must balance epistemic, feasibility and ethical justifications. Moreover, given their complexity, such studies need rigorous and informed ethical oversight.
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Affiliation(s)
- Carole A Federico
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA 98185, USA
| | - John Lantos
- Children's Mercy Hospital Bioethics Center, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | | | - Vasiliki Rahimzadeh
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Kevin Weinfurt
- Center for Health Measurement, Duke University, Durham, NC 27701, USA
| | - David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, MD 20892, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA 98185, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA.
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8
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Kim SY, Kimmelman J. Practical steps to identifying the research risk of pragmatic trials. Clin Trials 2022; 19:211-216. [PMID: 35348360 DOI: 10.1177/17407745211063476] [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
BACKGROUND Pragmatic randomized clinical trials that compare two or more purportedly "within the standard of care" interventions attempt to provide real-world evidence for policy and practice decisions. There is considerable debate regarding their research risk status, which in turn could lead to debates about appropriate consent requirements. Yet no practical guidance for identifying the research risks of pragmatic randomized clinical trials is available. METHODS We developed a practical, four-step process for identifying and evaluating the research risk of pragmatic trials that can be applied to those pragmatic randomized clinical trials that compare two or more "standard of care" or "accepted" interventions. RESULTS Using a variety of examples of standard of care pragmatic randomized clinical trials (ranging from trials comparing: insurance coverage conditions, patient reminders for health screens, intensive care unit procedures, post-stroke interventions, and drugs for life-threatening conditions), we illustrate in a four-step process how any pragmatic randomized clinical trial purportedly comparing standard interventions can be evaluated for their research risks. CONCLUSION Although determining the risk status of a standard of care pragmatic randomized clinical trial is only one necessary element in the ethical oversight of such pragmatic randomized clinical trials, it is a central element. Our four-step process of pragmatic randomized clinical trial risk determination provides a practical, transparent, and systematic approach with likely low risk of bias.
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Affiliation(s)
- Scott Yh Kim
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Jonathan Kimmelman
- Division of Ethics and Policy, School of Population and Global Health, McGill University, Montreal, QC, Canada
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Abstract
Deferred consent has gained traction in some countries as a possible adjunct to prospective consent for evaluating emergency therapies in the neonatal population. This form of consent has been shown to increase recruitment of acutely and critically unwell patients, potentially reduce parent decision-making burden, and provide more robust evidence for clinical treatments where equipoise exists. However, deferred consent raises complex ethical concerns and guidelines for its use vary across different jurisdictions. The views of all stakeholders, including neonatal providers and parents, are important in determining the appropriateness of deferred consent in high-risk patients. Deferred consent may be ethically justifiable for assessing various treatments, particularly those used in emergency medical management. We present a framework based on neonatal deferred consent trials that assess both non-drug and drug interventions, our experience conducting deferred consent neonatal studies in Australia, and the views of providers and parents on how to best implement deferred consent in the neonatal research setting.
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10
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Ali J, Davis AF, Burgess DJ, Rhon DI, Vining R, Young‐McCaughan S, Green S, Kerns RD. Justice and equity in pragmatic clinical trials: Considerations for pain research within integrated health systems. Learn Health Syst 2021; 6:e10291. [PMID: 35434355 PMCID: PMC9006531 DOI: 10.1002/lrh2.10291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/23/2021] [Accepted: 09/12/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Methods Results Conclusions
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Affiliation(s)
- Joseph Ali
- Department of International Health Johns Hopkins Bloomberg School of Public Health Baltimore Maryland USA
- Johns Hopkins Berman Institute of Bioethics Baltimore Maryland USA
| | - Alison F. Davis
- Pain Management Collaboratory, Department of Psychiatry Yale University School of Medicine New Haven Connecticut USA
| | - Diana J. Burgess
- VA HSR&D Center for Care Delivery and Outcomes Research, Minneapolis VA Medical Center Minneapolis Minnesota USA
- Department of Medicine University of Minnesota Medical School Minneapolis Minnesota USA
| | - Daniel I. Rhon
- Brooke Army Medical Center and Uniformed Services University of the Health Sciences Fort Sam Houston Texas USA
| | - Robert Vining
- Palmer Center for Chiropractic Research, Palmer College of Chiropractic Davenport Iowa USA
| | - Stacey Young‐McCaughan
- The University of Texas Health Science Center Houston Texas USA
- South Texas Veterans Health Care System San Antonio Texas USA
| | - Sean Green
- Pain Management Collaboratory, Department of Psychiatry Yale University School of Medicine New Haven Connecticut USA
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology, and Psychology Yale University New Haven Connecticut USA
- VA Connecticut Healthcare System Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center West Haven Connecticut USA
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11
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Carpenter JG, Ulrich C, Hodgson N, Hanson LC, Ersek M. Alternative Consent Models in Pragmatic Palliative Care Clinical Trials. J Pain Symptom Manage 2021; 62:183-191. [PMID: 33129936 PMCID: PMC8108441 DOI: 10.1016/j.jpainsymman.2020.09.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 01/14/2023]
Abstract
Palliative care research raises a host of ethical concerns. Obtaining informed consent from seriously ill patients and their families is often perceived as an additional burden. Alternative approaches to traditional written informed consent reflect the changing nature of modern trial design, embracing real-world effectiveness and pragmatic clinical trials with those who are seriously ill. Ethicists, clinical investigators, and regulatory bodies have acknowledged the challenges to rigorous, meaningful, and generalizable research across diverse patient populations in real-world settings. The purpose of this article is to describe how these clinical trial designs have driven innovation in methods for achieving informed consent, with a focus on palliative care research. In this article, we describe and provide examples of consent waivers and three types of alternative approaches to consent, including broadcast notification and integrated and targeted consent. We also present our experiences in an ongoing palliative care clinical trial, specifically using broadcast notification. Working with participants and regulatory oversight organizations, investigators can address the limits of traditional written informed consent and adopt innovative consent models to advance the science of palliative care. Research is now needed to determine the impact of these differing consent models on clinical trial recruitment, enrollment, and retention, as well as participants' informed understanding of their research participation using such models.
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Affiliation(s)
- Joan G Carpenter
- University of Maryland School of Nursing, Baltimore, Maryland, USA; Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.
| | - Connie Ulrich
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nancy Hodgson
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Laura C Hanson
- Division of Geriatric Medicine & Palliative Care Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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12
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Largent EA, Hey SP, Harkins K, Hoffman AK, Joffe S, Lima JC, London AJ, Karlawish J. Ethical and Regulatory Issues for Embedded Pragmatic Trials Involving People Living with Dementia. J Am Geriatr Soc 2021; 68 Suppl 2:S37-S42. [PMID: 32589273 DOI: 10.1111/jgs.16620] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 11/29/2022]
Abstract
Embedded pragmatic clinical trials (ePCTs) present an opportunity to improve care for people living with dementia (PLWD) and their care partners, but they also generate a complex constellation of ethical and regulatory challenges. These challenges begin with participant identification. Interventions may be delivered in ways that make it difficult to identify who is a human subject and therefore who needs ethical and regulatory protections. The need for informed consent, a core human subjects protection, must be considered but can be in tension with the goals of pragmatic research design. Thus it is essential to consider whether a waiver or alteration of informed consent is justifiable. If informed consent is needed, the question arises of how it should be obtained because researchers must acknowledge the vulnerability of PLWD due in part to diminished capacity and also to increased dependence on others. Further, researchers should recognize that many sites where ePCTs are conducted will be unfamiliar with human subjects research regulations and ethics. In this report, the Regulation and Ethics Core of the National Institute on Aging Imbedded Pragmatic Alzheimer's disease (AD) and AD-related dementias (AD/ADRD) Clinical Trials (IMPACT) Collaboratory discusses key ethical and regulatory challenges for ePCTs in PLWD. A central thesis is that researchers should strive to anticipate and address these challenges early in the design of their ePCTs as a means of both ensuring compliance and advancing science. J Am Geriatr Soc 68:S37-S42, 2020.
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Affiliation(s)
- Emily A Largent
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Kristin Harkins
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Allison K Hoffman
- University of Pennsylvania Carey Law School, Philadelphia, Pennsylvania, USA
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Julie C Lima
- Department of Health Services, Policy & Practice , Brown University School of Public Health, Providence, Rhode Island, USA.,Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Alex John London
- Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Jason Karlawish
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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13
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Panda PK, Stockler MR, Gulia A. Clinical research during coronavirus disease pandemic: Challenges and way forward. INDIAN JOURNAL OF MEDICAL SCIENCES 2020. [PMCID: PMC7485642 DOI: 10.25259/ijms_125_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
With the novel coronavirus disease (COVID-19) being declared a global pandemic by the World Health Organization, the Indian health-care sector is at the forefront to deliver optimal care but with constrained resources and several challenges. The pandemic has also brought about a state of urgency to develop suitable management principles for COVID-19 with the help of suitably designed clinical trials. However, the pandemic along with the lockdown and other restrictions has affected the conduct of clinical trials in terms of restrictions on travelling, trial site staff availability, investigational product availability, and medical oversight among others. This article provides structured recommendations for sponsors, investigators, clinical trial personnel to adapt to the situation by identifying potential risks and challenges and mitigating them to conduct clinical trials well within the ambit of local regulatory guidelines and requirements during the COVID-19 pandemic.
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Affiliation(s)
- Pankaj Kumar Panda
- Department of Clinical Research, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Martin R Stockler
- Department of Oncology, NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia,
| | - Ashish Gulia
- Department of Bone and Soft Tissue, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India,
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14
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Hueso M, de Haro L, Calabia J, Dal-Ré R, Tebé C, Gibert K, Cruzado JM, Vellido A. Leveraging Data Science for a Personalized Haemodialysis. KIDNEY DISEASES 2020; 6:385-394. [PMID: 33313059 DOI: 10.1159/000507291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 03/16/2020] [Indexed: 11/19/2022]
Abstract
Background The 2019 Science for Dialysis Meeting at Bellvitge University Hospital was devoted to the challenges and opportunities posed by the use of data science to facilitate precision and personalized medicine in nephrology, and to describe new approaches and technologies. The meeting included separate sections for issues in data collection and data analysis. As part of data collection, we presented the institutional ARGOS e-health project, which provides a common model for the standardization of clinical practice. We also pay specific attention to the way in which randomized controlled trials offer data that may be critical to decision-making in the real world. The opportunities of open source software (OSS) for data science in clinical practice were also discussed. Summary Precision medicine aims to provide the right treatment for the right patients at the right time and is deeply connected to data science. Dialysis patients are highly dependent on technology to live, and their treatment generates a huge volume of data that has to be analysed. Data science has emerged as a tool to provide an integrated approach to data collection, storage, cleaning, processing, analysis, and interpretation from potentially large volumes of information. This is meant to be a perspective article about data science based on the experience of the experts invited to the Science for Dialysis Meeting and provides an up-to-date perspective of the potential of data science in kidney disease and dialysis. Key messages Healthcare is quickly becoming data-dependent, and data science is a discipline that holds the promise of contributing to the development of personalized medicine, although nephrology still lags behind in this process. The key idea is to ensure that data will guide medical decisions based on individual patient characteristics rather than on averages over a whole population usually based on randomized controlled trials that excluded kidney disease patients. Furthermore, there is increasing interest in obtaining data about the effectiveness of available treatments in current patient care based on pragmatic clinical trials. The use of data science in this context is becoming increasingly feasible in part thanks to the swift developments in OSS.
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Affiliation(s)
- Miguel Hueso
- Department of Nephrology, Hospital Universitari Bellvitge, and Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Lluís de Haro
- Functional Competence Center, Information Systems, Institut Catalá de la Salut, Barcelona, Spain
| | - Jordi Calabia
- Department of Nephrology, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Rafael Dal-Ré
- Health Research Institute, Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| | - Cristian Tebé
- Biostatistics Unit, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Karina Gibert
- Intelligent Data Science and Artificial Intelligence (IDEAI) Research Center, Universitat Politècnica de Catalunya (UPC BarcelonaTech), Barcelona, Spain
| | - Josep M Cruzado
- Department of Nephrology, Hospital Universitari Bellvitge, and Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Alfredo Vellido
- Intelligent Data Science and Artificial Intelligence (IDEAI) Research Center, Universitat Politècnica de Catalunya (UPC BarcelonaTech), Barcelona, Spain
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15
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Abstract
There is intense debate around the use of altered and waived consent for pragmatic trials. Those in favor argue that traditional consent compromises the internal and external validity of these trials. Those against, warn that the resultant loss of autonomy compromises respect for persons and could undermine trust in the research enterprise.This article examines whether international ethical guidelines and the policy frameworks in three countries-the United States, England, and Australia-permit altered and waived consent for minimal-risk pragmatic trials conducted outside the emergency setting. Provisions for both are clearly articulated in U.S. regulations, but many countries do not have equivalent frameworks. Investigators should not assume that all consent models permitted in the United States are legal in their jurisdictions, even if they are deemed ethically defensible.The authors summarize ethical and regulatory considerations and present a framework for investigators contemplating trials with altered or waived consent.
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16
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den Boer MC, Houtlosser M, Foglia EE, Lopriore E, de Vries MC, Engberts DP, Te Pas AB. Deferred consent for delivery room studies: the providers' perspective. Arch Dis Child Fetal Neonatal Ed 2020; 105:310-315. [PMID: 31427459 DOI: 10.1136/archdischild-2019-317280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/22/2019] [Accepted: 08/03/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To gain insight into neonatal care providers' perceptions of deferred consent for delivery room (DR) studies in actual scenarios. METHODS We conducted semistructured interviews with 46 neonatal intensive care unit (NICU) staff members of the Leiden University Medical Center (the Netherlands) and the Hospital of the University of Pennsylvania (USA). At the time interviews were conducted, both NICUs conducted the same DR studies, but differed in their consent approaches. Interviews were audio-recorded, transcribed and analysed using the qualitative data analysis software Atlas.ti V.7.0. RESULTS Although providers reported to regard the prospective consent approach as the most preferable consent approach, they acknowledged that a deferred consent approach is needed for high-quality DR management. However, providers reported concerns about parental autonomy, approaching parents for consent and ethical review of study protocols that include a deferred consent approach. Providers furthermore differed in perceived appropriateness of a deferred consent approach for the studies that were being conducted at their NICUs. Providers with first-hand experience with deferred consent reported positive experiences that they attributed to appropriate communication and timing of approaching parents for consent. CONCLUSION Insight into providers' perceptions of deferred consent for DR studies in actual scenarios suggests that a deferred consent approach is considered acceptable, but that actual usage of the approach for DR studies can be improved on.
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Affiliation(s)
- Maria C den Boer
- Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands .,Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands
| | - Mirjam Houtlosser
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Enrico Lopriore
- Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Martine Charlotte de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands.,Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dirk P Engberts
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands
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17
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Brunette CA, Miller SJ, Majahalme N, Hau C, MacMullen L, Advani S, Ludin SA, Zimolzak AJ, Vassy JL. Pragmatic Trials in Genomic Medicine: The Integrating Pharmacogenetics In Clinical Care (I-PICC) Study. Clin Transl Sci 2020; 13:381-390. [PMID: 31808996 PMCID: PMC7070795 DOI: 10.1111/cts.12723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/31/2019] [Indexed: 12/19/2022] Open
Abstract
Pragmatic clinical trials (PCTs) have an established presence in clinical research and yet have only recently garnered attention within the landscape of genomic medicine. Using the PRagmatic-Explanatory Continuum Indicator Summary 2 (PRECIS-2) as a framework, this paper illustrates the application of PCT principles to The Integrating Pharmacogenetics In Clinical Care (I-PICC) Study, a trial of pharmacogenetic testing prior to statin initiation for cardiovascular disease prevention in primary care. The trial achieved high engagement with providers (85% enrolled of those approached) and enrolled a representative sample of participants for which statin therapy would be recommended. The I-PICC Study has a high level of pragmatism, which should enhance the generalizability of its findings. The PRECIS-2 may be useful in the design and evaluation of PCTs of genomic medicine interventions, contributing to the generation of evidence that can bridge the gap between genomics innovation and clinical adoption.
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Affiliation(s)
| | | | | | - Cynthia Hau
- VA Boston Healthcare SystemBostonMassachusettsUSA
| | | | | | - Sophie A. Ludin
- VA Boston Healthcare SystemBostonMassachusettsUSA
- Cornell UniversityIthacaNew YorkUSA
| | - Andrew J. Zimolzak
- VA Boston Healthcare SystemBostonMassachusettsUSA
- Baylor College of MedicineHoustonTexasUSA
- Michael E. DeBakey VA Medical CenterHoustonTexasUSA
| | - Jason L. Vassy
- VA Boston Healthcare SystemBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of General Internal Medicine and Primary CareBrigham and Women's HospitalBostonMassachusettsUSA
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18
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Dal-Ré R. Participants' written informed consent in low-risk pragmatic clinical trials with medicines. Expert Rev Clin Pharmacol 2020; 13:205-210. [PMID: 32073940 DOI: 10.1080/17512433.2020.1732816] [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: 10/25/2022]
Abstract
Introduction: An important gap within modern medicine is the lack of enough comparative effectiveness research of marketed medicines. Low-risk pragmatic randomized controlled trials (pRCTs) are those conducted resembling usual clinical practice that poses no or minimal incremental risk compared with normal clinical practice.Areas covered: This review addresses one important hurdle in the conduct of low-risk pRCTs: the need to seek participants' written informed consent.Expert opinion: The CIOMS ethical guidelines consider that any research that (a) would not be feasible or practicable to carry out without the waiver or modification, (b) has important social value, and (c) poses no more than minimal risks to participants, and that is approved by the relevant research ethics committee, could be conducted without participants' consent. It is clear that these provisions are applicable to some low-risk RCTs. Recently a research on the EU-CTR registry showed that only 2% of all ongoing phase 4 RCTs could have fulfilled the CIOMS provisions following the investigators' assessment. The EU clinical trial regulation - and that of other jurisdictions - should be debated on the suitableness of the conduct with an alteration or waiver of participants' consent of those low-risk pRCTs that fulfill the three CIOMS provisions.
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Affiliation(s)
- Rafael Dal-Ré
- Epidemiology Unit, Health Research Institute-Fundación Jiménez Díaz University Hospital, Universidad Autónoma De Madrid, Madrid, Spain
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19
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Shepherd L. The CER Experiment. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:49-51. [PMID: 31910137 DOI: 10.1080/15265161.2020.1689032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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20
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Kane PB, Kim SYH, Kimmelman J. What Research Ethics (Often) Gets Wrong about Minimal Risk. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:42-44. [PMID: 31910134 DOI: 10.1080/15265161.2019.1687789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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21
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Testing effectiveness of the revised Cape Town modified early warning and SBAR systems: a pilot pragmatic parallel group randomised controlled trial. Trials 2019; 20:809. [PMID: 31888745 PMCID: PMC6937946 DOI: 10.1186/s13063-019-3916-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 11/18/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nurses' recognition of clinical deterioration is crucial for patient survival. Evidence for the effectiveness of modified early warning scores (MEWS) is derived from large observation studies in developed countries. METHODS We tested the effectiveness of the paper-based Cape Town (CT) MEWS vital signs observation chart and situation-background-assessment-recommendation (SBAR) communication guide. Outcomes were: proportion of appropriate responses to deterioration, differences in recording of clinical parameters and serious adverse events (SAEs) in intervention and control trial arms. Public teaching hospitals for adult patients in Cape Town were randomised to implementation of the CT MEWS/SBAR guide or usual care (observation chart without track-and-trigger information) for 31 days on general medical and surgical wards. Nurses in intervention wards received training, as they had no prior knowledge of early warning systems. Identification and reporting of patient deterioration in intervention and control wards were compared. In the intervention arm, 24 day-shift and 23 night-shift nurses received training. Clinical records were reviewed retrospectively at trial end. Only records of patients who had given signed consent were reviewed. RESULTS We recruited two of six CT general hospitals. We consented 363 patients and analysed 292 (80.4%) patient records (n = 150, 51.4% intervention, n = 142, 48.6% control arm). Assistance was summoned for fewer patients with abnormal vital signs in the intervention arm (2/45, 4.4% versus (vs) 11/81, 13.6%, OR 0.29 (0.06-1.39)), particularly low systolic blood pressure. There was a significant difference in recording between trial arms for parameters listed on the MEWS chart but omitted from the standard observations chart: oxygen saturation, level of consciousness, pallor/cyanosis, pain, sweating, wound oozing, pedal pulses, glucose concentration, haemoglobin concentration, and "looks unwell". SBAR was used twice. There was no statistically significant difference in SAEs (5/150, 3.3% vs 3/143, 2.1% P = 0.72, OR 1.61 (0.38-6.86)). CONCLUSIONS The revised CT MEWS observations chart improved recording of certain parameters, but did not improve nurses' ability to identify early signs of clinical deterioration and to summon assistance. Recruitment of only two hospitals and exclusion of patients too ill to consent limits generalisation of results. Further work is needed on educational preparation for the CT MEWS/SBAR and its impact on nurses' reporting behaviour. TRIAL REGISTRATION Pan African Clinical Trials Registry, PACTR201406000838118. Registered on 2 June 2014, www.pactr.org.
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22
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Improving the promise of embedded pragmatic trials: Surmountable barriers encountered in an evaluation of home-based HPV self-sampling to increase cervical cancer screening in overdue women. Contemp Clin Trials Commun 2019; 15:100413. [PMID: 31372572 PMCID: PMC6661276 DOI: 10.1016/j.conctc.2019.100413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/10/2019] [Accepted: 07/18/2019] [Indexed: 12/23/2022] Open
Abstract
Despite increased attention on how to conduct pragmatic trials and their importance, there remains an under-appreciation for the reality of what they take to design, compete and secure funding and execute. Many barriers are surmountable through increased exposure to experiences from completed trials. This report summarizes our experience in designing, securing funding and implementing the Home-Based Options to Make screening Easier (HOME) pragmatic trial, which was designed to evaluate home human papillomavirus testing for cervical cancer screening in underscreened women (women who had not received a cervical cancer screening test in ≥3.5 years). This report highlights factors at the level of research teams, organizations seeking to conduct embedded research, reviewers and funding agencies that challenge pragmatic trial design and execution. There is an urgent need to train on peer-reviewers how to evaluate embedded trial grant proposals, for agencies to pursue more rapid and innovative funding strategies, and to consider strategies for reviewers and funders to evaluate stakeholder buy-in (beyond letters of support). These factors together are needed to realize the promise of pragmatic trials to more efficiently and effectively generate critical data that inform changes in health care delivery and benefit patients.
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23
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Kaye DK. The ethical justification for inclusion of neonates in pragmatic randomized clinical trials for emergency newborn care. BMC Pediatr 2019; 19:218. [PMID: 31266486 PMCID: PMC6607538 DOI: 10.1186/s12887-019-1600-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/25/2019] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Research guidelines generally recognize vulnerable populations to include neonates with the aim of enhancing protections from harm. In practice, such guidance results in limiting participation in randomized clinical trials (RCTs). Yet while medical care of neonates should be based on best research evidence to ensure that safe, efficacious treatment or procedures are used, this seldom happens in contemporary practice. DISCUSSION The compelling need to generate information on effectiveness and safety of procedures and medications that are already in use during neonatal care has led to increase in calls for pragmatic randomized clinical trials (PCTs). This raises ethical concerns as to whether exclusion of the vulnerable populations from research participations constitutes harm. First, neonates are denied access to both potentially beneficial research outputs and an opportunity to generate data on how interventions or medications perform in diverse clinical settings and inform clinical decision-making. Secondly, risks and harms in PCTs may differ from traditional RCTs, and can be reduced by modifications in study designs. The latter may involve assessment of effectiveness of comparable medication, devices or practices (whose safety data is available), randomization at the group level rather than at the individual level, avoidance of invasive and innovative study procedures, reliance on locally available data on relevant patient outcomes, and employment of procedures that tend to meet the criteria of minimal risk for human subject research. Thirdly, informed consent procedures should be modified from those of traditional RCTs, as neonates in traditional RCTs may be vulnerable to different extents in PCTs. Lastly, regulatory and oversight procedures designed for traditional RCT settings need modification, as they may not be translatable, feasible, appropriate or even ethical to apply in PCTs. CONCLUSION The principle of justice, commonly interpreted as preventing an inequitable burden of research, should also allow fair access to potential benefits from PCTs for neonates and other vulnerable populations. Under certain conditions, prospective randomized trials involving neonates should be ethically permissible to allow inclusion of neonates in research. This may require modification of the research design, consent procedures or regulations for research oversight.
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Affiliation(s)
- Dan Kabonge Kaye
- College of Health Sciences, Department of Obstetrics and Gynecology, Makerere University, P.O. Box 7072, Kampala, Uganda. .,Berman Institute of Bioethics, Johns Hopkins University, 1809 Ashland Avenue, Baltimore, 21205, USA.
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24
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Dal-Ré R, Avendaño-Solà C, de Boer A, James SK, Rosendaal FR, Stephens R, Ioannidis JPA. A limited number of medicines pragmatic trials had potential for waived informed consent following the 2016 CIOMS ethical guidelines. J Clin Epidemiol 2019; 114:60-71. [PMID: 31212001 DOI: 10.1016/j.jclinepi.2019.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/27/2019] [Accepted: 06/11/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES European regulations do not allow modification or waiver of informed consent for medicines randomized controlled trials (RCTs) where the three 2016 Council for International Organizations of Medical Sciences (CIOMS) provisions are met (consent would be impractical or unfeasible, yet the trial would have high social value and pose no or minimal risk to participants). We aimed to identify whether any such trials of medicines were being conducted in Europe. STUDY DESIGN AND SETTING This is a survey of all phase 4 "ongoing" RCTs on the EU clinical trial register between July 1, 2016 and June 30, 2018, to identify those with potentially high levels of pragmatism. Trials that were excluded were as follows: those conducted on rare diseases; conducted on healthy volunteers (except those assessing vaccines); masked (single-, double-blind) trials; single-center trials; those where one could expect to lead patients to prefer one intervention over the other; and miscellaneous reasons. The degree of pragmatism of the RCTs was self-assessed by trials' investigators by means of the PRECIS-2 tool. Investigators of those trials considered to be highly pragmatic assessed the fulfillment of the three CIOMS provisions. Seven patients assessed the social value of the RCTs. Finally, 33 members of 11 research ethics committees (RECs) assessed the social value of the trials and whether they posed no more than minimal risk to participants. Investigators, patients, and REC members assessed the fulfillment of the CIOMS provisions as "yes," "not sure" or "no." RESULTS Of the 638 phase 4 trials, 420 were RCTs, and 21 of these (5%) were candidates to be pragmatic. Investigators of 15 of these 21 RCTs self-assessed their trial's degree of pragmatism: 14 were highly pragmatic. Of these 14, eight fulfilled the three CIOMS provisions. Assessments by patients and RECs were inconsistent for several trials. CONCLUSIONS We found few low-risk participant-level pragmatic RCTs that could be suitable for modified or waived participants' informed consent. European regulators should consider amending the current regulation and encouraging the conduct of such trials.
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Affiliation(s)
- Rafael Dal-Ré
- Epidemiology Unit, Health Research Institute-Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, Avda Reyes Católicos 2, E-28040 Madrid, Spain.
| | - Cristina Avendaño-Solà
- Clinical Pharmacology Service, Puerta de Hierro University Hospital, Manuel de Falla 1, E-28222 Majadahonda, Madrid, Spain
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO Box 80082, 3508TB Utrecht, the Netherlands
| | - Stephan K James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Dag Hammarskölds väg 14B, SE-752 37 Uppsala, Sweden
| | - Frits R Rosendaal
- Department of Clinical Epidemiology C7-P, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, the Netherlands
| | - Richard Stephens
- National Cancer Research Institute's Consumer Forum, National Cancer Research Institute, Angel Building 407, St John Street, EC1V 4AD, London, UK
| | - John P A Ioannidis
- Departments of Medicine, Health Research and Policy, Biomedical Data Science and Statistics, and Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA 94305, USA
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25
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Melnick ER, Jeffery MM, Dziura JD, Mao JA, Hess EP, Platts-Mills TF, Solad Y, Paek H, Martel S, Patel MD, Bankowski L, Lu C, Brandt C, D’Onofrio G. User-centred clinical decision support to implement emergency department-initiated buprenorphine for opioid use disorder: protocol for the pragmatic group randomised EMBED trial. BMJ Open 2019; 9:e028488. [PMID: 31152039 PMCID: PMC6550013 DOI: 10.1136/bmjopen-2018-028488] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/12/2019] [Accepted: 04/24/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The goal of this trial is to determine whether implementation of a user-centred clinical decision support (CDS) system can increase adoption of initiation of buprenorphine (BUP) into the routine emergency care of individuals with opioid use disorder (OUD). METHODS A pragmatic cluster randomised trial is planned to be carried out in 20 emergency departments (EDs) across five healthcare systems over 18 months. The intervention consists of a user-centred CDS integrated into ED clinician electronic workflow and available for guidance to: (1) determine whether patients presenting to the ED meet criteria for OUD, (2) assess withdrawal symptoms and (3) ascertain and motivate patient willingness to initiate treatment. The CDS guides the ED clinician to initiate BUP and facilitate follow-up. The primary outcome is the rate of BUP initiated in the ED. Secondary outcomes are: (1) rates of receiving a referral, (2) fidelity with the CDS and (3) rates of clinicians providing any ED-initiated BUP, referral for ongoing treatment and receiving Drug Addiction Act of 2000 training. Primary and secondary outcomes will be analysed using generalised linear mixed models, with fixed effects for intervention status (CDS vs usual care), prespecified site and patient characteristics, and random effects for study site. ETHICS AND DISSEMINATION The protocol has been approved by the Western Institutional Review Board. No identifiable private information will be collected from patients. A waiver of informed consent was obtained for the collection of data for clinician prescribing and other activities. As a minimal risk implementation study of established best practices, an Independent Study Monitor will be utilised in place of a Data Safety Monitoring Board. Results will be reported in ClinicalTrials.gov and published in open-access, peer-reviewed journals, presented at national meetings and shared with the clinicians at participating sites via a broadcast email notification of publications. TRIAL REGISTRATION NUMBER NCT03658642; Pre-results.
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Affiliation(s)
- Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - James D Dziura
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jodi A Mao
- Emergency Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Erik P Hess
- Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Timothy F Platts-Mills
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Yauheni Solad
- Information Technology Services, Yale New-Haven Health, New Haven, Connecticut, USA
| | - Hyung Paek
- Information Technology Services, Yale New-Haven Health, New Haven, Connecticut, USA
| | - Shara Martel
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Laura Bankowski
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles Lu
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Cynthia Brandt
- Yale Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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26
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Dal-Ré R, Avendaño-Solà C, Bloechl-Daum B, de Boer A, Eriksson S, Fuhr U, Holm S, James SK, Mentz RJ, Perucca E, Rosendaal FR, Treweek S. Low risk pragmatic trials do not always require participants' informed consent. BMJ 2019; 364:l1092. [PMID: 30917969 DOI: 10.1136/bmj.l1092] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Rafael Dal-Ré
- Epidemiology Unit, Health Research Institute-Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, Avda Reyes Católicos 2, E-28040 Madrid, Spain
| | - Cristina Avendaño-Solà
- Clinical Pharmacology Service, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain
| | | | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, Netherlands
| | - Stefan Eriksson
- Centre for Research Ethics and Bioethics, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Uwe Fuhr
- Universityof Cologne Faculty of Medicine and University Hospital Cologne Centre of Pharmacology,Department I of Pharmacology, Clinical Pharmacology Unit, Cologne, Germany
| | - Søren Holm
- Centre for Social Ethics and Policy, School of Law, University of Manchester, Manchester, UK
| | - Stefan K James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Robert J Mentz
- Department of Medicine, Duke University Medical Centre and Clinical Research Institute, Durham, NC, USA
| | - Emilio Perucca
- Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Frits R Rosendaal
- Department of Clinical Epidemiology C7-P, Leiden University Medical Center, Leiden, The Netherlands
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Aberdeen , UK
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27
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Nicholls SG, Carroll K, Brehaut J, Weijer C, Hey SP, Goldstein CE, Zwarenstein M, Graham ID, McKenzie JE, McIntyre L, Jairath V, Campbell MK, Grimshaw JM, Fergusson DA, Taljaard M. Stakeholder views regarding ethical issues in the design and conduct of pragmatic trials: study protocol. BMC Med Ethics 2018; 19:90. [PMID: 30458809 PMCID: PMC6247737 DOI: 10.1186/s12910-018-0332-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/08/2018] [Indexed: 12/31/2022] Open
Abstract
Background Randomized controlled trial (RCT) trial designs exist on an explanatory-pragmatic spectrum, depending on the degree to which a study aims to address a question of efficacy or effectiveness. As conceptualized by Schwartz and Lellouch in 1967, an explanatory approach to trial design emphasizes hypothesis testing about the mechanisms of action of treatments under ideal conditions (efficacy), whereas a pragmatic approach emphasizes testing effectiveness of two or more available treatments in real-world conditions. Interest in, and the number of, pragmatic trials has grown substantially in recent years, with increased recognition by funders and stakeholders worldwide of the need for credible evidence to inform clinical decision-making. This increase has been accompanied by the onset of learning healthcare systems, as well as an increasing focus on patient-oriented research. However, pragmatic trials have ethical challenges that have not yet been identified or adequately characterized. The present study aims to explore the views of key stakeholders with respect to ethical issues raised by the design and conduct of pragmatic trials. It is embedded within a large, four-year project that seeks to develop guidance for the ethical design and conduct of pragmatic trials. As a first step, this study will address important gaps in the current empirical literature with respect to identifying a comprehensive range of ethical issues arising from the design and conduct of pragmatic trials. By opening up a broad range of topics for consideration within our parallel ethical analysis, we will extend the current debate, which has largely emphasized issues of consent, to the range of ethical considerations that may flow from specific design choices. Methods Semi-structured interviews with key stakeholders (e.g. trialists, methodologists, lay members of study teams, bioethicists, and research ethics committee members), across multiple jurisdictions, identified based on their known experience and/or expertise with pragmatic trials. Discussion We expect that the study outputs will be of interest to a wide range of knowledge users including trialists, ethicists, research ethics committees, journal editors, regulators, healthcare policymakers, research funders and patient groups. All publications will adhere to the Tri-Agency Open Access Policy on Publications. Electronic supplementary material The online version of this article (10.1186/s12910-018-0332-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada.
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada
| | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Spencer Phillips Hey
- Center for Bioethics, Harvard Medical School, Boston, MA, USA.,Program on Regulation, Therapeutics and Law (PORTAL), Brigham and Women's Hospital, Boston, MA, USA
| | - Cory E Goldstein
- Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Ian D Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Lauralyn McIntyre
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada
| | - Vipul Jairath
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | | | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada.,Faculty of Medicine, University of Ottawa, 501 Smyth Road, Box 201B, Ottawa, ON, K1H 8L6, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Fishman E, Barron J, Dinh J, Jones WS, Marshall A, Merkh R, Robertson H, Haynes K. Validation of a claims-based algorithm identifying eligible study subjects in the ADAPTABLE pragmatic clinical trial. Contemp Clin Trials Commun 2018; 12:154-160. [PMID: 30480162 PMCID: PMC6240793 DOI: 10.1016/j.conctc.2018.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/29/2018] [Accepted: 11/05/2018] [Indexed: 11/17/2022] Open
Abstract
Objective Validate an algorithm that uses administrative claims data to identify eligible study subjects for the ADAPTABLE (Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-Term Effectiveness) pragmatic clinical trial (PCT). Materials and methods This study used medical records from a random sample of patients identified as eligible for the ADAPTABLE trial. The inclusion criteria for ADAPTABLE were a history of acute myocardial infarction (AMI) or percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), or other coronary artery disease (CAD), plus at least one of several risk-enrichment factors. Exclusion criteria included a history of bleeding disorders or aspirin allergy. Using a claims-based algorithm, based on International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) and 10th Edition (ICD-10) codes and Current Procedural Terminology (CPT) codes, we identified patients eligible for the PCT. The primary outcome was the positive predictive value (PPV) of the identification algorithm: the proportion of sampled patients whose medical records confirmed their ADAPTABLE study eligibility. Exact 95% confidence limits for binomial random variables were calculated for the PPV estimates. Results Of the 185 patients whose medical records were reviewed, 168 (90.8%; 95% Confidence Interval: 85.7%, 94.6%) were confirmed study eligible. This proportion did not differ between patients identified with codes for AMI and patients identified with codes for PCI or CABG. Conclusion The estimated PPV was similar to those in claims-based identification of drug safety surveillance events, indicating that administrative claims data can accurately identify study-eligible subjects for pragmatic clinical trials.
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Affiliation(s)
- Ezra Fishman
- HealthCore, Inc., Wilmington, DE, USA
- Corresponding author. HealthCore, Inc. 123 Justison Street, Suite 200, Wilmington, DE 19801, USA.
| | | | - Jade Dinh
- HealthCore, Inc., Wilmington, DE, USA
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29
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Taljaard M, Weijer C, Grimshaw JM, Ali A, Brehaut JC, Campbell MK, Carroll K, Edwards S, Eldridge S, Forrest CB, Giraudeau B, Goldstein CE, Graham ID, Hemming K, Hey SP, Horn AR, Jairath V, Klassen TP, London AJ, Marlin S, Marshall JC, McIntyre L, McKenzie JE, Nicholls SG, Alison Paprica P, Zwarenstein M, Fergusson DA. Developing a framework for the ethical design and conduct of pragmatic trials in healthcare: a mixed methods research protocol. Trials 2018; 19:525. [PMID: 30261933 PMCID: PMC6161426 DOI: 10.1186/s13063-018-2895-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/31/2018] [Indexed: 01/03/2023] Open
Abstract
Background There is a widely recognized need for more pragmatic trials that evaluate interventions in real-world settings to inform decision-making by patients, providers, and health system leaders. Increasing availability of electronic health records, centralized research ethics review, and novel trial designs, combined with support and resources from governments worldwide for patient-centered research, have created an unprecedented opportunity to advance the conduct of pragmatic trials, which can ultimately improve patient health and health system outcomes. Such trials raise ethical issues that have not yet been fully addressed, with existing literature concentrating on regulations in specific jurisdictions rather than arguments grounded in ethical principles. Proposed solutions (e.g. using different regulations in “learning healthcare systems”) are speculative with no guarantee of improvement over existing oversight procedures. Most importantly, the literature does not reflect a broad vision of protecting the core liberty and welfare interests of research participants. Novel ethical guidance is required. We have assembled a team of ethicists, trialists, methodologists, social scientists, knowledge users, and community members with the goal of developing guidance for the ethical design and conduct of pragmatic trials. Methods Our project will combine empirical and conceptual work and a consensus development process. Empirical work will: (1) identify a comprehensive list of ethical issues through interviews with a small group of key informants (e.g. trialists, ethicists, chairs of research ethics committees); (2) document current practices by reviewing a random sample of pragmatic trials and surveying authors; (3) elicit views of chairs of research ethics committees through surveys in Canada, UK, USA, France, and Australia; and (4) elicit views and experiences of community members and health system leaders through focus groups and surveys. Conceptual work will consist of an ethical analysis of identified issues and the development of new ethical solutions, outlining principles, policy options, and rationales. The consensus development process will involve an independent expert panel to develop a final guidance document. Discussion Planned output includes manuscripts, educational materials, and tailored guidance documents to inform and support researchers, research ethics committees, journal editors, regulators, and funders in the ethical design and conduct of pragmatic trials.
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Affiliation(s)
- Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada. .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, 1151 Richmond Street, London, ON, N6A 5B7, Canada
| | - Jeremy M Grimshaw
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Adnan Ali
- Patient and Family Advisory Council, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jamie C Brehaut
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Marion K Campbell
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Sarah Edwards
- Department of Science and Technology Studies, University College London, 22 Gordon Square, King's Cross, London, WC1H 0AW, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, 58 Turner Street, London, E1 2AB, UK
| | - Christopher B Forrest
- Applied Clinical Research Center, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA
| | - Bruno Giraudeau
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France.,INSERM CIC1415, CHRU de Tours, Tours, France
| | - Cory E Goldstein
- Rotman Institute of Philosophy, Western University, 1151 Richmond Street, London, ON, N6A 5B7, Canada
| | - Ian D Graham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Spencer Phillips Hey
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.,Center for Bioethics, Harvard Medical School, Boston, MA, USA
| | - Austin R Horn
- Rotman Institute of Philosophy, Western University, 1151 Richmond Street, London, ON, N6A 5B7, Canada
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada.,Division of Epidemiology and Biostatistics, Western University, University Hospital, 339 Windermere Road, London, ON, N6A 5A5, Canada
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba, 513-715 McDermot Avenue, Winnipeg, MB, R3E 3P, Canada
| | - Alex John London
- Department of Philosophy and Center for Ethics and Policy, Carnegie Mellon University, 150A Baker Hall, Pittsburgh, PA, 15213-3890, USA
| | - Susan Marlin
- Clinical Trials Ontario, 661 University Avenue, MaRS Centre, West Tower, Toronto, ON, M5G 1M1, Canada
| | - John C Marshall
- St. Michael's Hospital, Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Lauralyn McIntyre
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.,Department of Medicine (Division of Critical Care), University of Ottawa, Ottawa, ON, Canada
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - P Alison Paprica
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Toronto, ON, M5T 3M6, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Department of Family Medicine Schulich School of Medicine & Dentistry Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Rehmann-Sutter C. Why Human Germline Editing is More Problematic than Selecting Between Embryos: Ethically Considering Intergenerational Relationships. New Bioeth 2018. [PMID: 29529985 DOI: 10.1080/20502877.2018.1441669] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Do we have a moral obligation to genetically cure embryos rather than selecting between them? Such an obligation would be an ethical argument for human germline gene editing (hGGE) to avoid the inheritance of genetic conditions instead of using pre-implantation genetic diagnosis (PGD). In this article, the intuition that we do have such a moral obligation is critically evaluated. The article first develops a theoretical framework for discussing the ethical questions of hGGE. This framework is based on an exploration of the phenomenology of the germline, from both biological and philosophical points of view. It interprets the germline as an embodied intergenerational relationship that carries meanings for the parents and for the children-to-be. It relates them to previous family generations, and to their own children. Hence, the germline is a phenomenologically much richer concept than just the line of cells that carry the inheritable genetic information. Against this background, selection is compared with editing and a key moral difference is identified: editing is in effect an act of co-constructing the genome, which necessarily assumes a wider range of responsibilities that include those parts that are left unedited. Introducing hGGE into societies would hence significantly affect and change the moral structure of the intergenerational relationships. Selective implantation, on the other hand (in the context of PGD), is based on a moral choice in favour of the embryo which is to be unaffected by a disease or disability that causes suffering, rather than selecting knowingly the affected one. The claim that hGGE is in the best interests of the child-to-be counterfactually assumes the presence of a patient who has an interest in being cured. The embryo (a potential future patient) is, however, brought into existence by the same act that is also the treatment. The future children who would result from treatment by hGGE may rather have an interest in not having been treated by hGGE, since it makes the intergenerational relationships more complicated and burdensome. The question 'Is hGGE justified, or even an obligation?' is answered with a No.
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Affiliation(s)
- Christoph Rehmann-Sutter
- a Institute of History of Medicine and Science Studies , University of Lübeck , Lubeck , Germany
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31
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Goldstein CE, Weijer C, Brehaut JC, Fergusson DA, Grimshaw JM, Horn AR, Taljaard M. Ethical issues in pragmatic randomized controlled trials: a review of the recent literature identifies gaps in ethical argumentation. BMC Med Ethics 2018; 19:14. [PMID: 29482537 PMCID: PMC5827974 DOI: 10.1186/s12910-018-0253-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 02/19/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Pragmatic randomized controlled trials (RCTs) are designed to evaluate the effectiveness of interventions in real-world clinical conditions. However, these studies raise ethical issues for researchers and regulators. Our objective is to identify a list of key ethical issues in pragmatic RCTs and highlight gaps in the ethics literature. METHODS We conducted a scoping review of articles addressing ethical aspects of pragmatic RCTs. After applying the search strategy and eligibility criteria, 36 articles were included and reviewed using content analysis. RESULTS Our review identified four major themes: 1) the research-practice distinction; 2) the need for consent; 3) elements that must be disclosed in the consent process; and 4) appropriate oversight by research ethics committees. 1) Most authors reject the need for a research-practice distinction in pragmatic RCTs. They argue that the distinction rests on the presumptions that research participation offers patients less benefit and greater risk than clinical practice, but neither is true in the case of pragmatic RCTs. 2) Most authors further conclude that pragmatic RCTs may proceed without informed consent or with simplified consent procedures when risks are low and consent is infeasible. 3) Authors who endorse the need for consent assert that information need only be disclosed when research participation poses incremental risks compared to clinical practice. Authors disagree as to whether randomization must be disclosed. 4) Finally, all authors view regulatory oversight as burdensome and a practical impediment to the conduct of pragmatic RCTs, and argue that oversight procedures ought to be streamlined when risks to participants are low. CONCLUSION The current ethical discussion is framed by the assumption that the function of research oversight is to protect participants from risk. As pragmatic RCTs commonly involve usual care interventions, the risks may be minimal. This leads many to reject the research-practice distinction and question the need for informed consent. But the function of oversight should be understood broadly as protecting the liberty and welfare interest of participants and promoting public trust in research. This understanding, we suggest, will focus discussion on questions about appropriate ethical review for pragmatic RCTs.
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Affiliation(s)
- Cory E Goldstein
- Rotman Institute of Philosophy, Western University, 1151 Richmond St., London, ON, N6A 5B7, Canada.
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, 1151 Richmond St., London, ON, N6A 5B7, Canada
| | - Jamie C Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Austin R Horn
- Rotman Institute of Philosophy, Western University, 1151 Richmond St., London, ON, N6A 5B7, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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32
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Weinfurt KP, Hernandez AF, Coronado GD, DeBar LL, Dember LM, Green BB, Heagerty PJ, Huang SS, James KT, Jarvik JG, Larson EB, Mor V, Platt R, Rosenthal GE, Septimus EJ, Simon GE, Staman KL, Sugarman J, Vazquez M, Zatzick D, Curtis LH. Pragmatic clinical trials embedded in healthcare systems: generalizable lessons from the NIH Collaboratory. BMC Med Res Methodol 2017; 17:144. [PMID: 28923013 PMCID: PMC5604499 DOI: 10.1186/s12874-017-0420-7] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/31/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The clinical research enterprise is not producing the evidence decision makers arguably need in a timely and cost effective manner; research currently involves the use of labor-intensive parallel systems that are separate from clinical care. The emergence of pragmatic clinical trials (PCTs) poses a possible solution: these large-scale trials are embedded within routine clinical care and often involve cluster randomization of hospitals, clinics, primary care providers, etc. Interventions can be implemented by health system personnel through usual communication channels and quality improvement infrastructure, and data collected as part of routine clinical care. However, experience with these trials is nascent and best practices regarding design operational, analytic, and reporting methodologies are undeveloped. METHODS To strengthen the national capacity to implement cost-effective, large-scale PCTs, the Common Fund of the National Institutes of Health created the Health Care Systems Research Collaboratory (Collaboratory) to support the design, execution, and dissemination of a series of demonstration projects using a pragmatic research design. RESULTS In this article, we will describe the Collaboratory, highlight some of the challenges encountered and solutions developed thus far, and discuss remaining barriers and opportunities for large-scale evidence generation using PCTs. CONCLUSION A planning phase is critical, and even with careful planning, new challenges arise during execution; comparisons between arms can be complicated by unanticipated changes. Early and ongoing engagement with both health care system leaders and front-line clinicians is critical for success. There is also marked uncertainty when applying existing ethical and regulatory frameworks to PCTS, and using existing electronic health records for data capture adds complexity.
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Affiliation(s)
- Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, 220 W Main St., Suite 720A, Durham, NC 27705 USA
- Duke Clinical Research Institute, 2400 Pratt St., Durham, NC 27710 USA
- Department of Psychology and Neuroscience, Duke Clinical Research Institute, Durham, NC 27710 USA
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, 2400 Pratt St., Durham, NC 27710 USA
- Duke University School of Medicine, 3115 N. Duke Street, Durham, NC 27704 USA
| | - Gloria D. Coronado
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR 97227-1098 USA
| | - Lynn L. DeBar
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR 97227-1098 USA
| | - Laura M. Dember
- Perelman School of MedicineBlockley Hall, Office 920, 423 Guardian Drive, Philadelphia, PA 19104 USA
| | - Beverly B. Green
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466 USA
| | - Patrick J. Heagerty
- University of Washington, 325 Ninth Ave, Box 359728, Seattle, WA 98104-2499 USA
| | - Susan S. Huang
- University of California Irvine School of Medicine, 101 The City Drive South, City Tower, Suite 400, Mail Code: 4081, Orange, CA 92868 USA
| | - Kathryn T. James
- University of Washington, 325 Ninth Ave, Box 359728, Seattle, WA 98104-2499 USA
| | - Jeffrey G. Jarvik
- University of Washington, 325 Ninth Ave, Box 359728, Seattle, WA 98104-2499 USA
| | - Eric B. Larson
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466 USA
| | - Vincent Mor
- Department of Community Health, Brown University, Box G-S121-2, Providence, RI 02912 USA
| | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215 USA
| | - Gary E. Rosenthal
- Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 USA
| | - Edward J. Septimus
- Hospital Corporation of America Nashville TN, AND Texas A&M College of Medicine, One Park Plaza, Nashville, TN 37203 USA
| | - Gregory E. Simon
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466 USA
| | | | - Jeremy Sugarman
- Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Ave., Room 203, Baltimore, MD 21205 USA
| | - Miguel Vazquez
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8856 USA
| | - Douglas Zatzick
- University of Washington School of Medicine, 325 9th Ave, Seattle, WA 98104 USA
| | - Lesley H. Curtis
- Duke Clinical Research Institute, 2400 Pratt St., Durham, NC 27710 USA
- Duke University School of Medicine, 3115 N. Duke Street, Durham, NC 27704 USA
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Dal-Ré R, Carcas AJ, Carné X, Wendler D. Patients' beliefs regarding informed consent for low-risk pragmatic trials. BMC Med Res Methodol 2017; 17:145. [PMID: 28923007 PMCID: PMC5604493 DOI: 10.1186/s12874-017-0424-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 09/10/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The requirement to obtain written informed consent may undermine the potential of pragmatic randomized clinical trials (pRCTs) to improve evidence-based care. This requirement could compromise trials statistical power or even force it to close them down prematurely. However, recent data from the U.S. and Spain suggest that a majority of the public endorses written consent for low-risk pRCTs. The present manuscript assesses whether this view is shared by patients. METHODS This was a cross-sectional, probability-based survey, with a 2 × 2 factorial design, assessing support for written informed consent versus verbal consent or general notification for two low-risk pRCTs in hypertension, one comparing 2 drugs with similar risk/benefit profiles and the other comparing the same drug being taken in the morning or at night. This web-based survey was conducted in May 2016. Two-thousand and eight adults who were representative of the Spanish population participated in the survey (response rate: 61%). Of these 2008 respondents, 338 indicated that they had been diagnosed with hypertension and were being treated with prescription medicines for this condition at the time of responding to the survey. The primary outcome measures were respondents' personal preference and recommendation to a research ethics committee regarding the use of written informed consent versus verbal consent or general notification. RESULTS Overall, 74% of the 338 patient respondents endorsed written consent. In both scenarios, general notification received significantly more support (30.6%-44.7%) than verbal consent (13.3%-17.6%). 43% of respondents preferred and/or recommended general notification rather than written consent. CONCLUSIONS As in the survey of the general public, more patients endorsed written consent than the alternative option. However, two factors suggest that a different approach to written consent should be investigated for low-risk pRCTs: a) a substantial minority of respondents supported general notification, b) data from the US have shown that most patients who prefer written consent are willing to forego it if obtaining written consent makes the trial too difficult to be conducted; and c) 2016 CIOMS guidelines endorse waivers of consent when the trial fulfills specific conditions. Surveys in other EU countries are needed to assess what patients believe towards pRCTs. If similar results to that reported in this study are found, it is foreseeable that with educational efforts, general notification could be an acceptable and widespread approach to the conduct of low-risk pRCTs.
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Affiliation(s)
- Rafael Dal-Ré
- Clinical Research, BUC (Biosciences UAM+CSIC) Program, International Campus of Excellence, Universidad Autónoma de Madrid, Ciudad Universitaria de Cantoblanco, Einstein 3, 28049, Madrid, Spain.
- Chair on Bioethics "Grifols Foundation", University of Vic - Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, E-08500, Vic, Barcelona, Spain.
- Epidemiology Unit, Health Research Institute-Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, Avda. Reyes Católicos 2, E-28040, Madrid, Spain.
| | - Antonio J Carcas
- Clinical Pharmacology Department, La Paz University Hospital, IdiPaz, School of Medicine, Universidad Autónoma de Madrid, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Xavier Carné
- Chair on Bioethics "Grifols Foundation", University of Vic - Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, E-08500, Vic, Barcelona, Spain
- Clinical Pharmacology Department, Clínic Hospital, August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Clinical Fundamentals Department, Universidad de Barcelona, Carrer de Villarroel 170, 08036, Barcelona, Spain
| | - David Wendler
- Section on Research Ethics, Department of Bioethics, NIH Clinical Center, 10 Center Dr, Bethesda, MD, 20814, USA
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Lie RK, Chan FK, Grady C, Ng VH, Wendler D. Comparative effectiveness research: what to do when experts disagree about risks. BMC Med Ethics 2017; 18:42. [PMID: 28629343 PMCID: PMC5477349 DOI: 10.1186/s12910-017-0202-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 06/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ethical issues related to comparative effectiveness research, or research that compares existing standards of care, have recently received considerable attention. In this paper we focus on how Ethics Review Committees (ERCs) should evaluate the risks of comparative effectiveness research. MAIN TEXT We discuss what has been a prominent focus in the debate about comparative effectiveness research, namely that it is justified when "nothing is known" about the comparative effectiveness of the available alternatives. We argue that this focus may be misleading. Rather, we should focus on the fact that some experts believe that the evidence points in favor of one intervention, whereas other experts believe that the evidence favors the alternative(s). We will then introduce a case that illustrates this point, and based on that, discuss how ERCs should deal with such cases of expert disagreement. CONCLUSION We argue that ERCs have a duty to assess the range of expert opinions and based on that assessment arrive at a risk judgment about the study under consideration. We also argue that assessment of expert disagreement is important for the assignment of risk level to a clinical trial: what is the basis for expert opinions, how strong is the evidence appealed to by various experts, and how can clinical trial monitoring affect the possible increased risk of clinical trial participation.
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Affiliation(s)
- Reidar K. Lie
- Department of Philosophy, University of Bergen, Sydnesplassen 12, 5020 Bergen, Norway
| | - Francis K.L. Chan
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administration Region, People’s Republic of China
| | - Christine Grady
- Department of Bioethics, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892 USA
| | - Vincent H. Ng
- Department of Mathematics and Science, Northern Virginia Community College, Woodbridge, VA 22191 USA
| | - David Wendler
- Department of Bioethics, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892 USA
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35
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Dal-Ré R, Carcas AJ, Carné X, Wendler D. Public preferences on written informed consent for low-risk pragmatic clinical trials in Spain. Br J Clin Pharmacol 2017; 83:1921-1931. [PMID: 28419518 PMCID: PMC5582372 DOI: 10.1111/bcp.13305] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 04/06/2017] [Accepted: 04/08/2017] [Indexed: 01/29/2023] Open
Abstract
Aims Pragmatic randomized clinical trials (pRCTs) collect data that have the potential to improve medical care significantly. However, these trials may be undermined by the requirement to obtain written informed consent, which can decrease accrual and increase selection bias. Recent data suggest that the majority of the US public endorses written consent for low‐risk pRCTs. The present study was designed to assess whether this view is specific to the US. Methods The study took the form of a cross‐sectional, probability‐based survey, with a 2 × 2 factorial design, assessing support for written informed consent vs. verbal consent or general notification for two low‐risk pRCTs in hypertension, one comparing two drugs with similar risk/benefit profiles and the other comparing the same drug being taken in the morning or at night. The primary outcome measures were respondents' personal preference and hypothetical recommendation to a research ethics committee regarding the use of written informed consent vs. the alternatives. Results A total of 2008 adults sampled from a probability‐based online panel responded to the web‐based survey conducted in May 2016 (response rate: 61%). Overall, 77% of respondents endorsed written consent. In both scenarios, the alternative of general notification received significantly more support (28.7–37.1%) than the alternative of verbal consent (12.7–14.0%) (P = 0.001). Forty per cent of respondents preferred and/or recommended general notification rather than written consent. Conclusions The results suggested that, rather than attempting to waive written consent, current pRCTs should focus on developing ways to implement written consent that provide sufficient information without undermining recruitment or increasing selection bias. The finding that around 40% of respondents endorsed general notification over written consent raises the possibility that, with educational efforts, the majority of Spaniards might accept general notification for low‐risk pRCTs.
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Affiliation(s)
- Rafael Dal-Ré
- Clinical Research, BUC (Biosciences UAM+CSIC) Program, International Campus of Excellence, Universidad Autónoma de Madrid, Ciudad Universitaria de Cantoblanco, Einstein 3, 28049, Madrid, Spain.,Chair on Bioethics 'Grifols Foundation', University of Vic-Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, 08500, Vic, Barcelona, Spain
| | - Antonio J Carcas
- Clinical Pharmacology Department, La Paz University Hospital, IdiPaz, School of Medicine, Universidad Autónoma de Madrid, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Xavier Carné
- Chair on Bioethics 'Grifols Foundation', University of Vic-Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, 08500, Vic, Barcelona, Spain.,Clinical Pharmacology Department, Clínic Hospital, August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Clinical Fundamentals Department, Universidad de Barcelona, Carrer de Villarroel 170, 08036, Barcelona, Spain.,Chair on Bioethics 'Grifols Foundation', University of Vic-Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, E-08500, Vic, Barcelona, Spain
| | - David Wendler
- Section on Research Ethics, Department of Bioethics, NIH Clinical Center, 10 Center Drive, Bethesda, MD, 20814,, USA
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Targeted Consent for Research on Standard of Care Interventions in the Emergency Setting. Crit Care Med 2017; 45:e105-e110. [PMID: 27509386 DOI: 10.1097/ccm.0000000000002023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES There has been significant debate over what consent process, if any, should be used for clinical trials that compare two or more interventions within the standard of care. Some claim that all clinical trials should obtain in-depth research consent because they use subjects to obtain data for the benefit of future patients. Others argue that clinical trials that are limited to interventions within the standard of care do not need to obtain research consent at all. Settling this debate is especially challenging in the emergency setting. The potential for significant morbidity and mortality provides a strong reason to obtain research consent for standard-of-care trials in the emergency setting. Yet, the emergency setting also introduces significant barriers to traditional in-depth research consent. The present article considers to what extent a targeted consent process can resolve these tensions. DATA SYNTHESIS We first identified the ethical goals that are promoted by obtaining consent for standard-of-care research and the barriers to obtaining consent that arise in the emergency setting. We then evaluated whether, despite the barriers, it is possible to develop a targeted consent process that promotes the goals for consent in the context of standard-of-care trials. CONCLUSIONS Targeted consent offers an ethically appropriate way to obtain consent for many standard-of-care trials in the emergency setting. For studies subject to U.S. regulations, and those subject to other regulations that include similar consent requirements, targeted consent's verbal disclosure and written form provide a way to satisfy research regulations without blocking valuable studies. For trials that qualify for a waiver of the consent requirements, targeted consent's verbal disclosure is preferable to waiving consent, provided a slight delay is consistent with appropriate care, and there is a capacitated patient or surrogate available.
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Dember LM, Archdeacon P, Krishnan M, Lacson E, Ling SM, Roy-Chaudhury P, Smith KA, Flessner MF. Pragmatic Trials in Maintenance Dialysis: Perspectives from the Kidney Health Initiative. J Am Soc Nephrol 2016; 27:2955-2963. [PMID: 27401689 PMCID: PMC5042681 DOI: 10.1681/asn.2016030340] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Pragmatic clinical trials are conducted under the real-world conditions of clinical care delivery. As a result, these trials yield findings that are highly generalizable to the nonresearch setting, identify interventions that are readily translatable into clinical practice, and cost less than trials that require extensive research infrastructures. Maintenance dialysis is a setting especially well suited for pragmatic trials because of inherently frequent and predictable patient encounters, highly granular and uniform data collection, use of electronic data systems, and delivery of care by a small number of provider organizations to approximately 90% of patients nationally. Recognizing the potential for pragmatic trials to generate much needed evidence to guide the care of patients receiving maintenance dialysis, the Kidney Health Initiative assembled a group of individuals with relevant expertise from academia, industry, and government to provide the nephrology community with information about the design and conduct of such trials, with a specific focus on the dialysis setting. Here, we review this information, and where applicable, use experience from the ongoing Time to Reduce Mortality in End Stage Renal Disease Trial, a large cluster-randomized, pragmatic trial evaluating hemodialysis session duration, to illustrate challenges and solutions to operational, ethical, and regulatory issues.
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Affiliation(s)
- Laura M Dember
- Renal, Electrolyte and Hypertension Division and Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;
| | - Patrick Archdeacon
- Office of Medical Policy and Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | - Eduardo Lacson
- Nephrology Division, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - Shari M Ling
- Center for Clinical Standards and Quality, Centers for Medicare and Medicaid Services, Baltimore, Maryland
| | - Prabir Roy-Chaudhury
- Division of Nephrology, The University of Arizona College of Medicine and Southern Arizona Veterans Administration Health Care System, Tucson, Arizona
| | - Kimberly A Smith
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Michael F Flessner
- Division of Kidney, Urology, and Hematology, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
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Chen SC, Kim SY. A framework for analysis of research risks and benefits to participants in standard of care pragmatic clinical trials. Clin Trials 2016; 13:605-611. [PMID: 27365010 DOI: 10.1177/1740774516656945] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIMS Standard of care pragmatic clinical trials that compare treatments already in use could improve care and reduce costs, but there is considerable debate about the research risks of standard of care pragmatic clinical trials and how to apply informed consent regulations to such trials. We sought to develop a framework integrating the insights from opposing sides of the debate. METHODS We developed a formal risk-benefit analysis framework for standard of care pragmatic clinical trials and then applied it to key provisions of the US federal regulations. RESULTS Our formal framework for standard of care pragmatic clinical trial risk-benefit analysis takes into account three key considerations: the ex ante estimates of risks and benefits of the treatments to be compared in a standard of care pragmatic clinical trial, the allocation ratios of treatments inside and outside such a trial, and the significance of some participants receiving a different treatment inside a trial than outside the trial. The framework provides practical guidance on how the research ethics regulations on informed consent should be applied to standard of care pragmatic clinical trials. CONCLUSION Our proposed formal model makes explicit the relationship between the concepts used by opposing sides of the debate about the research risks of standard of care pragmatic clinical trials and can be used to clarify the implications for informed consent.
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Affiliation(s)
- Stephanie C Chen
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Scott Yh Kim
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA .,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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McKinney RE, Beskow LM, Ford DE, Lantos JD, McCall J, Patrick-Lake B, Pletcher MJ, Rath B, Schmidt H, Weinfurt K. Use of altered informed consent in pragmatic clinical research. Clin Trials 2015; 12:494-502. [PMID: 26374677 PMCID: PMC4688909 DOI: 10.1177/1740774515597688] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There are situations in which the requirement to obtain conventional written informed consent can impose significant or even insurmountable barriers to conducting pragmatic clinical research, including some comparative effectiveness studies and cluster-randomized trials. Although certain federal regulations governing research in the United States (45 CFR 46) define circumstances in which any of the required elements may be waived, the same standards apply regardless of whether any single element is to be waived or whether consent is to be waived in its entirety. Using the same threshold for a partial or complete waiver limits the options available to institutional review boards as they seek to optimize a consent process. In this article, we argue that new standards are necessary in order to enable important pragmatic clinical research while at the same time protecting patients' rights and interests.
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Affiliation(s)
- Ross E McKinney
- Trent Center for Bioethics, Humanities, & History of Medicine and Division of Infectious Diseases, Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | | | - Daniel E Ford
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - John D Lantos
- Children's Mercy Bioethics Center, Children's Mercy Hospital, Kansas City, MO, US
| | | | - Bray Patrick-Lake
- Clinical Trials Transformation Initiative, Duke Translational Medicine Institute, Durham, NC, USA
| | - Mark J Pletcher
- Departments of Epidemiology and Biostatistics and Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Brian Rath
- Buchanan Ingersoll & Rooney PC, Princeton, NJ, USA
| | - Hollie Schmidt
- Accelerated Cure Project for Multiple Sclerosis, Waltham, MA, USA
| | - Kevin Weinfurt
- Duke Clinical Research Institute, Durham, NC, USA Department of Psychiatry, Duke University School of Medicine, Durham, NC, USA
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Ali J, Andrews JE, Somkin CP, Rabinovich CE. Harms, benefits, and the nature of interventions in pragmatic clinical trials. Clin Trials 2015; 12:467-75. [PMID: 26374680 PMCID: PMC4592413 DOI: 10.1177/1740774515597686] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
To produce evidence capable of informing healthcare decision making at all critical levels, pragmatic clinical trials are diverse both in terms of the type of intervention (medical, behavioral, and/or technological) and the target of intervention (patients, clinicians, and/or healthcare system processes). Patients and clinicians may be called on to participate as designers, investigators, intermediaries, or subjects of pragmatic clinical trials. Other members of the healthcare team, as well as the healthcare system itself, also may be affected directly or indirectly before, during, or after study implementation. This diversity in the types and targets of pragmatic clinical trial interventions has brought into focus the need to consider whether existing ethics and regulatory principles, policies, and procedures are appropriate for pragmatic clinical trials. Specifically, further examination is needed to identify how the types and targets of pragmatic clinical trial interventions may influence the assessment of net potential risk, understood as the balance of potential harms and benefits. In this article, we build on scholarship seeking to align ethics and regulatory requirements with potential research risks and propose an approach to the assessment of net risks that is sensitive to the diverse nature of pragmatic clinical trial interventions. We clarify the potential harms, burdens, benefits, and advantages of common types of pragmatic clinical trial interventions and discuss implications for patients, clinicians, and healthcare systems.
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Affiliation(s)
- Joseph Ali
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
| | | | - Carol P Somkin
- Kaiser Permanente Division of Research, Oakland, CA, USA
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Califf RM, Sugarman J. Exploring the ethical and regulatory issues in pragmatic clinical trials. Clin Trials 2015; 12:436-41. [PMID: 26374676 DOI: 10.1177/1740774515598334] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The need for high-quality evidence to support decision making about health and health care by patients, physicians, care providers, and policy-makers is well documented. However, serious shortcomings in evidence persist. Pragmatic clinical trials that use novel techniques including emerging information and communication technologies to explore important research questions rapidly and at a fraction of the cost incurred by more "traditional" research methods promise to help close this gap. Nevertheless, while pragmatic clinical trials can bridge clinical practice and research, they may also raise difficult ethical and regulatory challenges. In this article, the authors briefly survey the current state of evidence that is available to inform clinical care and other health-related decisions and discuss the potential for pragmatic clinical trials to improve this state of affairs. They then propose a new working definition for pragmatic research that centers upon fitness for informing decisions about health and health care. Finally, they introduce a project, jointly undertaken by the National Institutes of Health Health Care Systems Research Collaboratory and the National Patient-Centered Clinical Research Network (PCORnet), which addresses 11 key aspects of current systems for regulatory and ethical oversight of clinical research that pose challenges to conducting pragmatic clinical trials. In the series of articles commissioned on this topic published in this issue of Clinical Trials, each of these aspects is addressed in a dedicated article, with a special focus on the interplay between ethical and regulatory considerations and pragmatic clinical research aimed at informing "real-world" choices about health and health care.
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Affiliation(s)
- Robert M Califf
- Division of Cardiology, Department of Medicine, School of Medicine, Duke University, Durham, NC, USA Duke Translational Medicine Institute, Duke University, Durham, NC, USA Current affiliation: US Food and Drug Administration, Silver Spring, MD, USA. This paper was submitted prior to Dr. Califf's appointment to the US Food and Drug Administration
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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O'Rourke PP, Carrithers J, Patrick-Lake B, Rice TW, Corsmo J, Hart R, Drezner MK, Lantos JD. Harmonization and streamlining of research oversight for pragmatic clinical trials. Clin Trials 2015; 12:449-56. [PMID: 26374678 DOI: 10.1177/1740774515597685] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The oversight of research involving human participants is a complex process that requires institutional review board review as well as multiple non-institutional review board institutional reviews. This multifaceted process is particularly challenging for multisite research when each site independently completes all required local reviews. The lack of inter-institutional standardization can result in different review outcomes for the same protocol, which can delay study operations from start-up to study completion. Hence, there have been strong calls to harmonize and thus streamline the research oversight process. Although the institutional review board is only one of the required reviews, it is often identified as the target for harmonization and streamlining. Data regarding variability in decision-making and interpretation of the regulations across institutional review boards have led to a perception that variability among institutional review boards is a primary contributor to the problems with review of multisite research. In response, many researchers and policymakers have proposed the use of a single institutional review board of record, also called a central institutional review board, as an important remedy. While this proposal has merit, the use of a central institutional review board for multisite research does not address the larger problem of completing non-institutional review board institutional review in addition to institutional review board review—and coordinating the interdependence of these reviews. In this article, we describe the overall research oversight process, distinguish between institutional review board and institutional responsibilities, and identify challenges and opportunities for harmonization and streamlining. We focus on procedural and organizational issues and presume that the protection of human subjects remains the paramount concern. Suggested modifications of institutional review board processes that focus on time, efficiency, and consistency of review must also address what effect such changes have on the quality of review. We acknowledge that assessment of quality is difficult in that quality metrics for institutional review board review remain elusive. At best, we may be able to assess the time it takes to review protocols and the consistency across institutions.
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Affiliation(s)
| | | | - Bray Patrick-Lake
- Clinical Trials Transformation Initiative, Duke University, Durham, NC, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Jeremy Corsmo
- Office of Research Compliance and Regulatory Affairs, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Raffaella Hart
- Biomedical Research Alliance of New York, Lake Success, NY, USA
| | - Marc K Drezner
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - John D Lantos
- Children's Mercy Bioethics Center, Children's Mercy Hospital, Kansas City, MO, USA
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