1
|
Morain SR, O'Rourke PP, Ali J, Rahimzadeh V, Check DK, Bosworth HB, Sugarman J. Post-trial responsibilities in pragmatic clinical trials: Fulfilling the promise of research to drive real-world change. Learn Health Syst 2024; 8:e10413. [PMID: 39036536 PMCID: PMC11257052 DOI: 10.1002/lrh2.10413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/22/2023] [Accepted: 02/16/2024] [Indexed: 07/23/2024] Open
Abstract
While considerable scholarship has explored responsibilities owed to research participants at the conclusion of explanatory clinical trials, no guidance exists regarding responsibilities owed at the conclusion of a pragmatic clinical trial (PCT). Yet post-trial responsibilities in PCTs present distinct considerations from those emphasized in existing guidance and prior scholarship. Among these considerations include the responsibilities of the healthcare delivery systems in which PCTs are embedded, and decisions about implementation for interventions that demonstrate meaningful benefit following their integration into usual care settings-or deimplementation for those that fail to do so. In this article, we present an overview of prior scholarship and guidance on post-trial responsibilities, and then identify challenges for post-trial responsibilities for PCTs. We argue that, given one of the key rationales for PCTs is that they can facilitate uptake of their results by relevant decision-makers, there should be a presumptive default that PCT study results be incorporated into future care delivery processes. Fulfilling this responsibility will require prospective planning by researchers, healthcare delivery system leaders, institutional review boards, and sponsors, so as to ensure that the knowledge gained from PCTs does, in fact, influence real-world practice.
Collapse
Affiliation(s)
- Stephanie R. Morain
- Berman Institute of BioethicsJohns Hopkins UniversityBaltimoreMarylandUSA
- Department of Health Policy & ManagementBloomberg School of Public HealthBaltimoreMarylandUSA
| | | | - Joseph Ali
- Berman Institute of BioethicsJohns Hopkins UniversityBaltimoreMarylandUSA
- Department of International HealthBloomberg School of Public HealthBaltimoreMarylandUSA
| | - Vasiliki Rahimzadeh
- Center for Medical Ethics and Health PolicyBaylor College of MedicineHoustonTexasUSA
| | - Devon K. Check
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Hayden B. Bosworth
- Department of Population Health SciencesDuke University School of MedicineDurhamNorth CarolinaUSA
| | - Jeremy Sugarman
- Berman Institute of BioethicsJohns Hopkins UniversityBaltimoreMarylandUSA
- Department of Health Policy & ManagementBloomberg School of Public HealthBaltimoreMarylandUSA
- Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| |
Collapse
|
2
|
Morain SR, Bollinger J, Weinfurt K, Sugarman J. Stakeholder perspectives on data sharing from pragmatic clinical trials: Unanticipated challenges for meeting emerging requirements. Learn Health Syst 2024; 8:e10366. [PMID: 38249837 PMCID: PMC10797577 DOI: 10.1002/lrh2.10366] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction Numerous arguments have been advanced for broadly sharing de-identified, participant-level clinical trial data. However, data sharing in pragmatic clinical trials (PCTs) presents ethical challenges. While prior scholarship has described aspects of PCTs that raise distinct considerations for data sharing, there have been no reports of the experiences of those at the leading edge of data-sharing efforts for PCTs, including how these particular challenges have been navigated. To address this gap, we conducted interviews with key stakeholders, with a focus on the ethical issues presented by sharing data from PCTs. Methods We recruited respondents using purposive sampling to reflect the range of stakeholder groups affected by efforts to expand PCT data sharing. Through semi-structured interviews, we explored respondents' experiences and perceptions about sharing de-identified, individual-level data from PCTs. An integrated approach was used to identify and describe key themes. Results We conducted 40 interviews between April and September 2022. Five overarching themes emerged through analysis: (1) challenges in sharing data collected under a waiver or alteration of consent; (2) conflicting views regarding PCT patient-subject preferences for data sharing; (3) identification of respect-promoting practices beyond consent; (4) concerns about elevated risks or burdens from sharing PCT data; and (5) diverse views about the likely benefits resulting from sharing PCT data. Conclusion Our data indicate unresolved tensions in how to fulfill the expectation to broadly share de-identified, individual-level data from PCTs, and suggest that those promulgating and implementing data-sharing policies must be sensitive to PCT-specific considerations. Future work could inform efforts to tailor data-sharing policy and practice to reflect the challenges presented by PCTs, including sharing experiences from trials that have successfully navigated these tensions.
Collapse
Affiliation(s)
- Stephanie R. Morain
- Berman Insitute of BioethicsJohns Hopkins UniversityBaltimoreMarylandUSA
- Department of Health Policy & ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Juli Bollinger
- Berman Insitute of BioethicsJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Kevin Weinfurt
- Department of Population Health SciencesDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Jeremy Sugarman
- Berman Insitute of BioethicsJohns Hopkins UniversityBaltimoreMarylandUSA
- Department of Health Policy & ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of MedicineSchool of Medicine, Johns HopkinsBaltimoreMarylandUSA
| |
Collapse
|
3
|
Morain S, Largent E. Think Pragmatically: Investigators' Obligations to Patient-Subjects When Research is Embedded in Care. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:10-21. [PMID: 35435790 PMCID: PMC9576818 DOI: 10.1080/15265161.2022.2063435] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Growing interest in embedded research approaches-where research is incorporated into clinical care-has spurred numerous studies to generate knowledge relevant to the real-world needs of patients and other stakeholders. However, it also has presented ethical challenges. An emerging challenge is how to understand the nature and extent of investigators' obligations to patient-subjects. Prior scholarship on investigator duties has generally been grounded upon the premise that research and clinical care are distinct activities, bearing distinct duties. Yet this premise-and its corresponding implications-are challenged when research and clinical care are deliberately integrated. After presenting three case studies from recent pragmatic clinical trials, we identify six differences between explanatory trials and embedded research that limit the application of existing scholarship for ascertaining investigator duties. We suggest that these limitations indicate a need to account for the implications of usual care and to move beyond a narrow focus on the investigator-subject dyad, one that better reflects the team- and institution-based nature of contemporary health systems.
Collapse
|
4
|
Clapp JT, Dinh C, Hsu M, Neuman MD. Clinical reasoning in pragmatic trial randomization: a qualitative interview study. Trials 2023; 24:431. [PMID: 37365614 PMCID: PMC10294416 DOI: 10.1186/s13063-023-07445-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/08/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Pragmatic trials, because they study widely used treatments in settings of routine practice, require intensive participation from clinicians who determine whether patients can be enrolled. Clinicians are often conflicted between their therapeutic obligation to patients and their willingness to enroll them in trials in which treatments are randomly determined and thus potentially suboptimal. Refusal to enroll eligible patients can hinder trial completion and damage generalizability. In order to help evaluate and mitigate clinician refusal, this qualitative study examined how clinicians reason about whether to randomize eligible patients. METHODS We performed interviews with 29 anesthesiologists who participated in REGAIN, a multicenter pragmatic randomized trial comparing spinal and general anesthesia in hip fracture. Interviews included a chart-stimulated section in which physicians described their reasoning pertaining to specific eligible patients as well as a general semi-structured section about their views on clinical research. Guided by a constructivist grounded theory approach, we analyzed data via coding, synthesized thematic patterns using focused coding, and developed an explanation using abduction. RESULTS Anesthesiologists perceived their main clinical function as preventing peri- and intraoperative complications. In some cases, they used prototype-based reasoning to determine whether patients with contraindications should be randomized; in others, they used probabilistic reasoning. These modes of reasoning involved different types of uncertainty. In contrast, anesthesiologists expressed confidence about anesthetic options when they accepted patients for randomization. Anesthesiologists saw themselves as having a fiduciary responsibility to patients and thus did not hesitate to communicate their inclinations, even when this complicated trial recruitment. Nevertheless, they voiced strong support for clinical research, stating that their involvement was mainly hindered by production pressure and workflow disruptions. CONCLUSIONS Our findings suggest that prominent ways of assessing clinician decisions about trial randomization are based on questionable assumptions about clinical reasoning. Close examination of routine clinical practice, attuned to the features of clinical reasoning we reveal here, will help both in evaluating clinicians' enrollment determinations in specific trials and in anticipating and responding to them. TRIAL REGISTRATION Regional Versus General Anesthesia for Promoting Independence After Hip Fracture (REGAIN). CLINICALTRIALS gov NCT02507505. Prospectively registered on July 24, 2015.
Collapse
Affiliation(s)
- Justin T Clapp
- Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Blockley Hall, 3rd floor, 423 Guardian Dr, PA, 19104, Philadelphia, USA.
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | | | - Monica Hsu
- Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Mark D Neuman
- Department of Anesthesiology & Critical Care, University of Pennsylvania Perelman School of Medicine, Blockley Hall, 3rd floor, 423 Guardian Dr, PA, 19104, Philadelphia, USA
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
5
|
Khan MS, Usman MS, Talha KM, Van Spall HGC, Greene SJ, Vaduganathan M, Khan SS, Mills NL, Ali ZA, Mentz RJ, Fonarow GC, Rao SV, Spertus JA, Roe MT, Anker SD, James SK, Butler J, McGuire DK. Leveraging electronic health records to streamline the conduct of cardiovascular clinical trials. Eur Heart J 2023; 44:1890-1909. [PMID: 37098746 DOI: 10.1093/eurheartj/ehad171] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 02/05/2023] [Accepted: 03/07/2023] [Indexed: 04/27/2023] Open
Abstract
Conventional randomized controlled trials (RCTs) can be expensive, time intensive, and complex to conduct. Trial recruitment, participation, and data collection can burden participants and research personnel. In the past two decades, there have been rapid technological advances and an exponential growth in digitized healthcare data. Embedding RCTs, including cardiovascular outcome trials, into electronic health record systems or registries may streamline screening, consent, randomization, follow-up visits, and outcome adjudication. Moreover, wearable sensors (i.e. health and fitness trackers) provide an opportunity to collect data on cardiovascular health and risk factors in unprecedented detail and scale, while growing internet connectivity supports the collection of patient-reported outcomes. There is a pressing need to develop robust mechanisms that facilitate data capture from diverse databases and guidance to standardize data definitions. Importantly, the data collection infrastructure should be reusable to support multiple cardiovascular RCTs over time. Systems, processes, and policies will need to have sufficient flexibility to allow interoperability between different sources of data acquisition. Clinical research guidelines, ethics oversight, and regulatory requirements also need to evolve. This review highlights recent progress towards the use of routinely generated data to conduct RCTs and discusses potential solutions for ongoing barriers. There is a particular focus on methods to utilize routinely generated data for trials while complying with regional data protection laws. The discussion is supported with examples of cardiovascular outcome trials that have successfully leveraged the electronic health record, web-enabled devices or administrative databases to conduct randomized trials.
Collapse
Affiliation(s)
- Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd., Durham, NC 27705, USA
| | - Muhammad Shariq Usman
- Department of Medicine, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA
| | - Khawaja M Talha
- Department of Medicine, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA
| | - Harriette G C Van Spall
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd., Durham, NC 27705, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sadiya S Khan
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
- Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Ziad A Ali
- DeMatteis Cardiovascular Institute, St Francis Hospital and Heart Center, Roslyn, NY, USA
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd., Durham, NC 27705, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Gregg C Fonarow
- Division of Cardiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Sunil V Rao
- Division of Cardiology, New York University Langone Health System, New York, NY, USA
| | - John A Spertus
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- Kansas City's Healthcare Institute for Innovations in Quality, University of Missouri, Kansas, MO, USA
| | - Matthew T Roe
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd., Durham, NC 27705, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Stefan K James
- Department of Medical Sciences, Scientific Director UCR, Uppsala University, Uppsala, Uppland, Sweden
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA
- Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX, USA
| |
Collapse
|
6
|
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.
Collapse
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.
| |
Collapse
|
7
|
Califf RM. The Ecosystem to Support People with Heart Failure. J Card Fail 2021; 28:650-658. [PMID: 34752906 DOI: 10.1016/j.cardfail.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 01/28/2023]
Affiliation(s)
- Robert M Califf
- Verily Life Sciences and Google Health (Alphabet), South San Francisco, California.
| |
Collapse
|
8
|
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
Collapse
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
| |
Collapse
|
9
|
Nicholls SG, Carroll K, Goldstein CE, Brehaut JC, Weijer C, Zwarenstein M, Dixon S, Grimshaw JM, Garg AX, Taljaard M. Patient Partner Perspectives Regarding Ethically and Clinically Important Aspects of Trial Design in Pragmatic Cluster Randomized Trials for Hemodialysis. Can J Kidney Health Dis 2021; 8:20543581211032818. [PMID: 34367647 PMCID: PMC8317238 DOI: 10.1177/20543581211032818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cluster randomized trials (CRTs) are trials in which intact groups such as hemodialysis centers or shifts are randomized to treatment or control arms. Pragmatic CRTs have been promoted as a promising trial design for nephrology research yet may also pose ethical challenges. While randomization occurs at the cluster level, the intervention and data collection may vary in a CRT, challenging the identification of research participants. Moreover, when a waiver of patient consent is granted by a research ethics committee, there is an open question as to whether and to what degree patients should be notified about ongoing research or be provided with a debrief regarding the nature and results of the trial upon completion. While empirical and conceptual research exploring ethical issues in pragmatic CRTs has begun to emerge, there has been limited discussion with patients, families, or caregivers of patients undergoing hemodialysis. OBJECTIVE To explore with patients and families with experience of hemodialysis research the challenges raised by different approaches to designing pragmatic CRTs in hemodialysis. Specifically, their perceptions of (1) the use of a waiver of consent, (2) notification processes and information provided to participants, and (3) any other concerns about cluster randomized designs in hemodialysis. DESIGN Focus group and interview discussions of hypothetical clinical trial designs. SETTING Focus groups and interviews were conducted in-person or via videoconference or telephone. PARTICIPANTS Patient partners in hemodialysis research, defined as patients with personal experience of dialysis or a family member who had experience supporting a patient receiving hemodialysis, who have been actively involved in discussions to advise a research team on the design, conduct, or implementation of a hemodialysis trial. METHODS Participants were invited to participate in focus groups or individual discussions that were audio recorded with consent. Recorded interviews were transcribed verbatim prior to analysis. Transcripts were analyzed using a thematic analysis approach. RESULTS Two focus groups, three individual interviews, and one interview involving a patient and family member were conducted with 17 individuals between February 2019 and May 2020. Participants expressed support for approaches that emphasized patient choice. Disclosure of patient-relevant risks and information were key themes. Both consent and notification processes served to generate trust, but bypassing patient choice was perceived as undermining this trust. Participants did not dismiss the option of a waiver of consent. They were, however, more restrictive in their views about when a waiver of consent may be acceptable. Patient partners were skeptical of claims to impracticability based on costs or the time commitments for staff. LIMITATIONS All participants were from Canada and had been involved in the design or conduct of a trial, limiting the degree to which results may be extrapolated. CONCLUSIONS Given the preferences of participants to be afforded the opportunity to decide about trial participation, we argue that investigators should thoroughly investigate approaches that allow participants to make an informed choice regarding trial participation. In keeping with the preference for autonomous choice, there remains a need to further explore how consent approaches can be designed to facilitate clinical trial conduct while meeting their ethical requirements. Finally, further work is needed to define the limited circumstances in which waivers of consent are appropriate.
Collapse
Affiliation(s)
- Stuart G. Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
| | | | - Jamie C. Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
| | - Charles Weijer
- Department of Philosophy, Western University, London, ON, Canada
- Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Western University, London, ON, Canada
- Department of Family Medicine, Western University, London, ON, Canada
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- ICES, Ontario, Canada
| | - Stephanie Dixon
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- ICES, Ontario, Canada
- Lawson Research Institute, London, ON, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, ON, Canada
| | - Amit X. Garg
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- ICES, Ontario, Canada
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
- Nephrology, London Health Sciences Centre, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Morain SR, Largent EA. Public Attitudes toward Consent When Research Is Integrated into Care-Any "Ought" from All the "Is"? Hastings Cent Rep 2021; 51:22-32. [PMID: 33840104 DOI: 10.1002/hast.1242] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Research that is integrated into ongoing clinical activities holds the potential to accelerate the generation of knowledge to improve the health of individuals and populations. Yet integrating research into clinical care presents difficult ethical and regulatory challenges, including how or whether to obtain informed consent. Multiple empirical studies have explored patients' and the public's attitudes toward approaches to consent for pragmatic research. Questions remain, however, about how to use the resulting empirical data in resolving normative and policy debates and what kind of data warrants the most consideration. We recommend prioritizing data about what people consider acceptable with respect to consent for pragmatic research and data about people's informed, rather than initial, preferences on this subject. In addition, we advise caution regarding the weight given to majority viewpoints and identify circumstances when empirical data can be overridden. We argue that empirical data bolster normative arguments that alterations of consent should be the default in pragmatic research; waivers are appropriate only when the pragmatic research would otherwise be impracticable and has sufficiently high social value.
Collapse
|
12
|
Partnering with healthcare facilities to understand psychosocial distress screening practices among cancer survivors: pilot study implications for study design, recruitment, and data collection. BMC Health Serv Res 2021; 21:238. [PMID: 33731095 PMCID: PMC7968218 DOI: 10.1186/s12913-021-06250-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We sought to understand barriers and facilitators to implementing distress screening (DS) of cancer patients to inform and promote uptake in cancer treatment facilities. We describe the recruitment and data collection challenges and recommendations for assessing DS in oncology treatment facilities. METHODS We recruited CoC-accredited facilities and collected data from each facility's electronic health record (EHR). Collected data included cancer diagnosis and demographics, details on DS, and other relevant patient health data. Data were collected by external study staff who were given access to the facility's EHR system, or by facility staff working locally within their own EHR system. Analyses are based on a pilot study of 9 facilities. RESULTS Challenges stemmed from being a multi-facility-based study and local institutional review board (IRB) approval, facility review and approval processes, and issues associated with EHR systems and the lack of DS data standards. Facilities that provided study staff remote-access took longer for recruitment; facilities that performed their own extraction/abstraction took longer to complete data collection. CONCLUSION Examining DS practices and follow-up among cancer survivors necessitated recruiting and working directly with multiple healthcare systems and facilities. There were a number of lessons learned related to recruitment, enrollment, and data collection. Using the facilitators described in this manuscript offers increased potential for working successfully with various cancer centers and insight into partnering with facilities collecting non-standardized DS clinical data.
Collapse
|
13
|
Bell JAH, Kelly MT, Gelmon K, Chi K, Ho A, Rodney P, Balneaves LG. Gatekeeping in cancer clinical trials in Canada: The ethics of recruiting the "ideal" patient. Cancer Med 2020; 9:4107-4113. [PMID: 32314549 PMCID: PMC7300392 DOI: 10.1002/cam4.3031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/28/2020] [Accepted: 03/12/2020] [Indexed: 01/11/2023] Open
Abstract
Background Perspectives of clinical trial (CT) personnel on accrual to oncology CTs are relatively absent from the literature. This study explores CT personnel's experience recruiting patients to oncology CTs. Methods A qualitative study design was utilized. In‐depth, individual interviews with 12 oncology CT personnel were conducted, including six CT nurses and six physician‐investigators. Interviews were digitally recorded and transcribed verbatim. Data were subjected to thematic and ethical analysis to identify key concepts and themes. Results CT personnel reported considering two ethical commitments in CT recruitment: maintaining trial integrity and ensuring patient autonomy through obtaining informed consent. The process of gatekeeping emerged as a way to navigate these ethical commitments during CT accrual. Gatekeeping was influenced by: (a) perceptions of patients’ personal suitability for a trial, and (b) healthcare resources and infrastructure. CT personnel's discernment of personal suitability was influenced by patients’ cognitive and mental health status, language and cultural background, geographic location, family support, and disease status. Three structural factors impacted gatekeeping: complexity of CTs, consent process, and time limitations in the healthcare system. CT personnel experienced most factors as constraints to accrual and gaining patients’ informed consent. Conclusion CT personnel discussed navigating ethical challenges in CT recruitment by offering enrollment to specific patient populations, exacerbating other ethical tensions. Systems‐level strategies are needed to address barriers to ethical CT recruitment. Future research should investigate the role of policies and/or tools (eg, decision aids) to support patients and CT personnel's discussions about CT participation, promote more ethical recruitment, and potentially increase accrual.
Collapse
Affiliation(s)
- Jennifer A H Bell
- University of Toronto, Toronto, ON, Canada.,Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Karen Gelmon
- University of British Columbia, Vancouver, BC, Canada
| | - Kim Chi
- University of British Columbia, Vancouver, BC, Canada
| | - Anita Ho
- University of British Columbia, Vancouver, BC, Canada.,University of California, Oakland, CA, USA.,Centre for Health Evaluation & Outcomes Sciences, University of British Columbia, Vancouver, BC, Canada
| | | | | |
Collapse
|
14
|
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.
Collapse
|
15
|
Nicholls SG, Carroll K, Zwarenstein M, Brehaut JC, Weijer C, Hey SP, Goldstein CE, Graham ID, Grimshaw JM, McKenzie JE, Fergusson DA, Taljaard M. The ethical challenges raised in the design and conduct of pragmatic trials: an interview study with key stakeholders. Trials 2019; 20:765. [PMID: 31870433 PMCID: PMC6929346 DOI: 10.1186/s13063-019-3899-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/08/2019] [Indexed: 12/20/2022] Open
Abstract
Background There is a concern that the apparent effectiveness of interventions tested in clinical trials may not be an accurate reflection of their actual effectiveness in usual practice. Pragmatic randomized controlled trials (RCTs) are designed with the intent of addressing this discrepancy. While pragmatic RCTs may increase the relevance of research findings to practice they may also raise new ethical concerns (even while reducing others). To explore this question, we interviewed key stakeholders with the aim of identifying potential ethical challenges in the design and conduct of pragmatic RCTs with a view to developing future guidance on these issues. Methods Interviews were conducted with clinical investigators, methodologists, patient partners, ethicists, and other knowledge users (e.g., regulators). Interviews covered experiences with pragmatic RCTs, ethical issues relevant to pragmatic RCTs, and perspectives on the appropriate oversight of pragmatic RCTs. Interviews were coded inductively by two coders. Interim and final analyses were presented to the broader team for comment and discussion before the analytic framework was finalized. Results We conducted 45 interviews between April and September 2018. Interviewees represented a range of disciplines and jurisdictions as well as varying content expertise. Issues of importance in pragmatic RCTs were (1) identification of relevant risks from trial participation and determination of what constitutes minimal risk; (2) determining when alterations to traditional informed consent approaches are appropriate; (3) the distinction between research, quality improvement, and practice; (4) the potential for broader populations to be affected by the trial and what protections they might be owed; (5) the broader range of trial stakeholders in pragmatic RCTs, and determining their roles and responsibilities; and (6) determining what constitutes “usual care” and implications for trial reporting. Conclusions Our findings suggest both the need to discuss familiar ethical topics in new ways and that there are new ethical issues in pragmatic RCTs that need greater attention. Addressing the highlighted issues and developing guidance will require multidisciplinary input, including patient and community members, within a broader and more comprehensive analysis that extends beyond consent and attends to the identified considerations relating to risk and stakeholder roles and responsibilities.
Collapse
Affiliation(s)
- Stuart G Nicholls
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.
| | - Kelly Carroll
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Jamie C Brehaut
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Spencer P Hey
- Center for Bioethics, Harvard Medical School and Program on Regulation, Therapeutics, and Law at Brigham and Women's Hospital, Boston, MA, USA
| | - Cory E Goldstein
- Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Ian D Graham
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Department of Medicine University of Ottawa, Ottawa Hospital Research Institute (OHRI), ON, Ottawa, Canada
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dean A Fergusson
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Department of Medicine University of Ottawa, Ottawa Hospital Research Institute (OHRI), ON, Ottawa, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | | |
Collapse
|
16
|
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.
Collapse
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.
| |
Collapse
|
17
|
Bisdas T, Bohan P, Lescan M, Zeebregts CJ, Tessarek J, van Herwaarden J, van den Berg JC, Setacci C, Riambau V. Research methodology and practical issues relating to the conduct of a medical device registry. Clin Trials 2019; 16:490-501. [PMID: 31184490 DOI: 10.1177/1740774519855395] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The postmarket research goal is to assess "generalizability" or "external validity" to see if the early results of clinical trials with investigational devices are reproducible in everyday practice in the real world and the longer term. Registries have an important but ambivalent role in achieving this goal. METHODS Although registries are common, in practice they follow the regulatory processes that appear designed primarily for pharmaceutical clinical trials and confirmatory studies. We review the literature to assess different definitions and the role of registries in the hierarchy of scientific evidence. We analyze common characteristics affecting registry design, implementation, and governance as well as safety reporting and off-label use while describing the experience of setting up an international, prospective registry for an endovascular device used to treat abdominal aortic aneurysms. RESULTS Key areas in which to distinguish registries from trials are as follows: eligibility, setting (patients and institutions), device configurations and iterations, the use of design and quality "spaces," a focus on systematic quality checks (rather than source data monitoring), open-ended follow-up, flexibility in the definition of end points and sample sizes, data sharing, and publishing commitments. CONCLUSION Both clinical trials and registries are essential and complementary research methods and the strengths and weaknesses of each need to be recognized. The specific characteristics of registry research deserve to be acknowledged and safeguarded in the regulations governing clinical investigations with medical devices.
Collapse
Affiliation(s)
- Theodosios Bisdas
- St. Franziskus-Hospital Münster GmbH, Münster, Germany.,Clinic of Vascular and Endovascular Therapy, Omilos Iatrikou Athinon, Athens, Greece
| | | | - Mario Lescan
- Universitätsklinikum Tübingen Medizinische Universitätsklinik, Tübingen, Germany
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jörg Tessarek
- St. Bonifatius Hospital Lingen gGmbH, Lingen, Germany
| | - Joost van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Carlo Setacci
- AOU Senese, Vascular and Endovascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | | |
Collapse
|
18
|
Lipman PD, Dluzak L, Stoney CM. Is this study feasible? Facilitating management of pragmatic trial planning milestones under a phased award funding mechanism. Trials 2019; 20:307. [PMID: 31146778 PMCID: PMC6543574 DOI: 10.1186/s13063-019-3387-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 04/30/2019] [Indexed: 11/26/2022] Open
Abstract
Background Improving efficiencies in clinical research is crucial to translation of findings into practice and delivery of effective, patient-centered health care. This paper describes a project that monitored pragmatic clinical trials by working with investigators to track achievement of early phase milestones. The National Institutes of Health (NIH) Pragmatic Trials Collaborative Project supported scientifically diverse, low-cost, randomized, controlled, pragmatic clinical intervention trials. Funds were available through a cooperative agreement award mechanism, with the initial phase supporting trial planning and the subsequent 4-year awards funding trial implementation. A coordinating center provided evaluation and administrative support, which included capturing progress toward achieving milestones. Methods Six funded trials participated in monthly calls throughout the first year to identify and demonstrate metrics and deliverables for each milestone in the Notice of Grant Award. Interviews were conducted with investigators, trial team members, and NIH program officers/project scientists to discuss their perceptions of the impact and value of the management strategy. Results Five of six trials transitioned to the implementation phase with milestones ranging from 6 to 15 and quantifiable metrics ranging from 15 to 33, for a total of 121 deliverables. One third of the metrics (42, 35%) were trial-specific. Trial teams reported that the oversight was onerous but complemented their management strategies; program officers/project scientists found that documentation submitted for review was sufficient to assess trial feasibility; and investigators reported advantages to the phased award mechanism, such as leverage to secure commitments from stakeholders and collaborators, help with task prioritization, and earlier consultation with key members of the trial team. Conclusions Implementing systematic approaches to identify milestones and track metrics can strengthen the evidence base regarding time and effort to plan and conduct pragmatic clinical trials. Investigators were unaccustomed to producing evidence of performance, and it was challenging to determine what documentation to provide. Efforts to standardize expectations regarding milestones that mark a significant change or stage in trial development or that represent minimum success criteria may provide guidance for more effective and efficient trial management. A framework with clearly specified metrics is especially critical for transparency, particularly when funding decisions are contingent on both merit and feasibility.
Collapse
Affiliation(s)
| | - Leanora Dluzak
- Westat, 1600 Research Boulevard, Rockville, MD, 20850, USA
| | - Catherine M Stoney
- National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), 6701 Rockledge Drive, Bethesda, MD, 20817, USA
| |
Collapse
|
19
|
Littleton-Kearney M. Pragmatic clinical trials at the National Institute of Nursing Research. Nurs Outlook 2018; 66:470-472. [DOI: 10.1016/j.outlook.2018.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 02/06/2018] [Indexed: 11/30/2022]
|
20
|
Johnson AM, Jones SB, Duncan PW, Bushnell CD, Coleman SW, Mettam LH, Kucharska-Newton AM, Sissine ME, Rosamond WD. Hospital recruitment for a pragmatic cluster-randomized clinical trial: Lessons learned from the COMPASS study. Trials 2018; 19:74. [PMID: 29373987 PMCID: PMC5787294 DOI: 10.1186/s13063-017-2434-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 12/29/2017] [Indexed: 11/10/2022] Open
Abstract
Background Pragmatic randomized clinical trials are essential to determine the effectiveness of interventions in “real-world” clinical practice. These trials frequently use a cluster-randomized methodology, with randomization at the site level. Despite policymakers’ increased interest in supporting pragmatic randomized clinical trials, no studies to date have reported on the unique recruitment challenges faced by cluster-randomized pragmatic trials. We investigated key challenges and successful strategies for hospital recruitment in the Comprehensive Post-Acute Stroke Services (COMPASS) study. Methods The COMPASS study is designed to compare the effectiveness of the COMPASS model versus usual care in improving functional outcomes, reducing the numbers of hospital readmissions, and reducing caregiver strain for patients discharged home after stroke or transient ischemic attack. This model integrates early supported discharge planning with transitional care management, including nurse-led follow-up phone calls after 2, 30, and 60 days and an in-person clinic visit at 7–14 days involving a functional assessment and neurological examination. We present descriptive statistics of the characteristics of successfully recruited hospitals compared with all eligible hospitals, reasons for non-participation, and effective recruitment strategies. Results We successfully recruited 41 (43%) of 95 eligible North Carolina hospitals. Leading, non-exclusive reasons for non-participation included: insufficient staff or financial resources (n = 33, 61%), lack of health system support (n = 16, 30%), and lack of support of individual decision-makers (n = 11, 20%). Successful recruitment strategies included: building and nurturing relationships, engaging team members and community partners with a diverse skill mix, identifying gatekeepers, finding mutually beneficial solutions, having a central institutional review board, sharing published pilot data, and integrating contracts and review board administrators. Conclusions Although we incorporated strategies based on the best available evidence at the outset of the study, hospital recruitment required three times as much time and considerably more staff than anticipated. To reach our goal, we tailored strategies to individuals, hospitals, and health systems. Successful recruitment of a sufficient number and representative mix of hospitals requires considerable preparation, planning, and flexibility. Strategies presented here may assist future trial organizers in implementing cluster-randomized pragmatic trials. Trial registration Clinicaltrials.gov, NCT02588664. Registered on 23 October 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2434-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Anna M Johnson
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA.
| | - Sara B Jones
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA
| | - Pamela W Duncan
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Sylvia W Coleman
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Laurie H Mettam
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA
| | - Anna M Kucharska-Newton
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA
| | - Mysha E Sissine
- Department of Neurology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, 27157, USA
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, 2101 McGavran-Greenberg Hall, CB #7435, Chapel Hill, NC, 27599-7435, USA
| |
Collapse
|
21
|
Abstract
Pragmatic clinical trials (PCTs) are a relatively new methodological approach to the execution of clinical research that can increase research efficiency and provide access to unique data. Some have suggested that the costs and delays associated with obtaining informed consent could make PCTs difficult or even impossible to execute. Alternative consent models have been proposed, some of which lower standards of disclosure, delay consent, or waive it altogether. We analyze the permissibility of changes to informed consent in the context of Canadian research ethics policies, legislation, common law, professional codes of ethics, and professional standards of practice. We find that Canadian law and policy relating to informed consent clearly applies to any clinician who might be involved in a PCT. In addition, existing consent norms seem unable to accommodate alternative consent models for pragmatic research if such models would involve lowering the standard of disclosure. The strong emphasis on the primacy of individual rights that exist in law and in research ethics norms cannot easily coexist with strategies that involve either waiver of consent requirements or the provision of incomplete information about the research prior to enrolment. If Canadian policy-makers wish to create the regulatory flexibility necessary to accommodate altered consent and disclosure, it is likely this will require the alteration of existing health information legislation, national research ethics policy, and professional standards.
Collapse
|
22
|
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: 123] [Impact Index Per Article: 17.6] [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.
Collapse
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
| |
Collapse
|
23
|
Topazian R, Bollinger J, Weinfurt KP, Dvoskin R, Mathews D, Brelsford K, DeCamp M, Sugarman J. Physicians' perspectives regarding pragmatic clinical trials. J Comp Eff Res 2016; 5:499-506. [PMID: 27417953 DOI: 10.2217/cer-2016-0024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Practicing physicians inevitably become involved in pragmatic clinical trials (PCTs), including comparative effectiveness research. We sought to identify physicians' perspectives related to PCTs. METHODS In-depth semistructured interviews with 20 physicians in the USA. RESULTS Although physicians are generally willing to participate in PCTs, their support is predicated on several factors including expected benefits, minimization of time and workflow burdens and physician engagement. Physicians communicated a desire to respect patients' rights and interests while maintaining a high level of care. CONCLUSION Future work is needed to systematically assess the impact of PCTs on clinicians in meeting their ethical obligations to patients and the burdens clinicians are willing to accept in exchange for potential benefits.
Collapse
Affiliation(s)
- Rachel Topazian
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Juli Bollinger
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Kevin P Weinfurt
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.,Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Rachel Dvoskin
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Debra Mathews
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Kathleen Brelsford
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Matthew DeCamp
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA.,Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA.,Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.,Department of Health Policy & Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
24
|
Smalley JB, Merritt MW, Al-Khatib SM, McCall D, Staman KL, Stepnowsky C. Ethical responsibilities toward indirect and collateral participants in pragmatic clinical trials. Clin Trials 2015; 12:476-84. [PMID: 26374687 PMCID: PMC4812163 DOI: 10.1177/1740774515597698] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pragmatic clinical trials are designed to inform decision makers about the benefits, burdens, and risks of health interventions in real-world settings. Pragmatic clinical trials often use for research purposes data collected in the course of clinical practice. The distinctive features of pragmatic clinical trials demand fresh thinking about what is required to act properly toward people affected by their conduct, in ways that go beyond ensuring the protection of rights and welfare for "human research subjects" under conventional research ethics regulations. To stimulate such work, we propose to distinguish among categories of research participants in pragmatic clinical trials as follows: Direct participants: (1) individuals being directly intervened upon and/or (2) individuals from whom personal identifiable data are being collected for the purposes of the pragmatic clinical trial. Indirect participants: individuals who are (1) not identified as direct participants and (2) whose rights and welfare may be affected by the intervention through their routine exposure to the environment in which the intervention is being deployed. Collateral participants: patient groups and other stakeholder communities who may be otherwise affected by the occurrence and findings of the pragmatic clinical trial. We illustrate these distinctions with case examples and discuss the distinctive responsibilities of researchers and pragmatic clinical trial leadership toward each type of participant. We suggest that pragmatic clinical trial investigators, institutional review boards, health systems leaders, and others engaged in the research enterprise work together to identify these participants. For indirect participants, risks and benefits to which they are exposed should be weighed to ensure that their rights and welfare are protected accordingly, and communication strategies should be considered to help them make well-informed decisions. Collateral participants could provide input on the design, planning, and conduct of a pragmatic clinical trial and offer insights regarding the best way to communicate the trial's results to their constituencies.
Collapse
Affiliation(s)
- Jaye Bea Smalley
- Patient-Centered Outcomes Research Institute (PCORI), Washington, DC, USA
| | - Maria W Merritt
- Berman Institute of Bioethics and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | |
Collapse
|
25
|
Finkelstein JA, Brickman AL, Capron A, Ford DE, Gombosev A, Greene SM, Iafrate RP, Kolaczkowski L, Pallin SC, Pletcher MJ, Staman KL, Vazquez MA, Sugarman J. Oversight on the borderline: Quality improvement and pragmatic research. Clin Trials 2015; 12:457-66. [PMID: 26374685 DOI: 10.1177/1740774515597682] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pragmatic research that compares interventions to improve the organization and delivery of health care may overlap, in both goals and methods, with quality improvement activities. When activities have attributes of both research and quality improvement, confusion often arises about what ethical oversight is, or should be, required. For routine quality improvement, in which the delivery of health care is modified in minor ways that create only minimal risks, oversight by local clinical or administrative leaders utilizing institutional policies may be sufficient. However, additional consideration should be given to activities that go beyond routine, local quality improvement to first determine whether such non-routine activities constitute research or quality improvement and, in either case, to ensure that independent oversight will occur. This should promote rigor, transparency, and protection of patients' and clinicians' rights, well-being, and privacy in all such activities. Specifically, we recommend that (1) health care organizations should have systematic policies and processes for designating activities as routine quality improvement, non-routine quality improvement, or quality improvement research and determining what oversight each will receive. (2) Health care organizations should have formal and explicit oversight processes for non-routine quality improvement activities that may include input from institutional quality improvement experts, health services researchers, administrators, clinicians, patient representatives, and those experienced in the ethics review of health care activities. (3) Quality improvement research requires review by an institutional review board; for such review to be effective, institutional review boards should develop particular expertise in assessing quality improvement research. (4) Stakeholders should be included in the review of non-routine quality improvement and quality improvement-related research proposals. Only by doing so will we optimally leverage both pragmatic research on health care delivery and local implementation through quality improvement as complementary activities for improving health.
Collapse
Affiliation(s)
- Jonathan A Finkelstein
- Division of General Pediatrics, Boston Children's Hospital, Departments of Pediatrics and Population Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Alexander Capron
- Gould School of Law and Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Daniel E Ford
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Adrijana Gombosev
- School of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Sarah M Greene
- Patient-Centered Outcomes Research Institute, Washington, DC, USA
| | | | - Laura Kolaczkowski
- Multiple Sclerosis Patient-Powered Research Network, University of Dayton, Dayton, OH, USA
| | | | | | | | - Miguel A Vazquez
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeremy Sugarman
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
| |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|