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Lake AK, Bansiya V, Davenport K, Murdoch J, Murphy HR, Smith T, Clark A, Arthur A. Proactive review for people with diabetes in hospital: a cluster randomised feasibility trial with process evaluation, protocol V3.1. Pilot Feasibility Stud 2024; 10:88. [PMID: 38863071 PMCID: PMC11165828 DOI: 10.1186/s40814-024-01507-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 05/10/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Diabetes inpatient specialist services vary across the country, with limited evidence to guide service delivery. Currently, referrals to diabetes inpatient specialists are usually 'reactive' after diabetes-related events have taken place, which are associated with an increased risk of morbidity/mortality and increased length of hospital stay. We propose that a proactive diabetes review model of care, delivered by diabetes inpatient specialist nurses, may contribute to the prevention of such diabetes-related events and result in a reduction in the risk of harm. METHOD We will conduct a cluster randomised feasibility study with process evaluation. The proactive diabetes review model (PDRM) is a complex intervention that focuses on the prevention of potentially modifiable diabetes-related harms. All eligible patients will receive a comprehensive, structured diabetes review that aims to identify and prevent potentially modifiable diabetes-related harms through utilising a standardised review structure. Reviews are undertaken by a diabetes inpatient specialist nurse within one working day of admission. This differs from usual care where patients are often only seen after diabetes-related harms have taken place. The trial duration will be approximately 32 weeks, with intervention delivery throughout. There will be an initial 8-week run-in phase, followed by a 24-week data collection phase. Eight wards will be equally randomised to either PDRM or usual care. Adult patients with a known diagnosis of diabetes admitted to an included ward will be eligible. Data collection will be limited to that typically collected as part of usual care. Data collected will include descriptive data at both the ward and patient level and glucose measures, such as frequency and results of capillary glucose testing, ketonaemia and hypoglycaemic events. The analysis aims to determine the fidelity and acceptability of the intervention and the feasibility of a future definitive trial. Whilst this study is primarily about trial feasibility, the findings of the process evaluation may lead to changes to both trial processes and modifications to the intervention. A qualitative process evaluation will be conducted in parallel to the trial. A minimum of 22 patients, nurses, doctors, and managers will be recruited with methods including direct non-participant observation and semi-structured interviews. The feasibility of a future definitive trial will be assessed by evaluating recruitment and randomisation processes, staffing resources and quality of available data. DISCUSSION The aim of this cluster randomised feasibility trial with a process evaluation is to explore the feasibility of a definitive trial and identify appropriate outcome measures. If a trial is feasible and the effectiveness of PDRM can be evaluated, this could inform the future development of inpatient diabetes services nationally. TRIAL REGISTRATION UK Clinical Research Network, 51,167. ISRCTN, ISRCTN70402110. Registered on 21 February 2022.
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Affiliation(s)
- Andrea K Lake
- The Wolfson Diabetes & Endocrine Clinic , Cambridge University Hospitals NHS Foundation Trust, Hills Road, Box 281, Cambridge, CB20QQ, UK.
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK.
| | - Vishakha Bansiya
- The Wolfson Diabetes & Endocrine Clinic , Cambridge University Hospitals NHS Foundation Trust, Hills Road, Box 281, Cambridge, CB20QQ, UK
| | - Katy Davenport
- The Wolfson Diabetes & Endocrine Clinic , Cambridge University Hospitals NHS Foundation Trust, Hills Road, Box 281, Cambridge, CB20QQ, UK
| | - Jamie Murdoch
- School of Life Course and Population Sciences, Faculty of Life Sciences & Medicine, King's College London, 5Th Floor, Addison House, Guy's Campus, London, SE1 1UL, UK
| | - Helen R Murphy
- The Wolfson Diabetes & Endocrine Clinic , Cambridge University Hospitals NHS Foundation Trust, Hills Road, Box 281, Cambridge, CB20QQ, UK
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Toby Smith
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Antony Arthur
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, NR4 7TJ, UK
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Ryan EG, Gao CX, Grantham KL, Thao LTP, Charles-Nelson A, Bowden R, Herschtal A, Lee KJ, Forbes AB, Heritier S, Phillipou A, Wolfe R. Advancing randomized controlled trial methodologies: The place of innovative trial design in eating disorders research. Int J Eat Disord 2024; 57:1337-1349. [PMID: 38469971 DOI: 10.1002/eat.24187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/26/2024] [Accepted: 02/26/2024] [Indexed: 03/13/2024]
Abstract
Randomized controlled trials can be used to generate evidence on the efficacy and safety of new treatments in eating disorders research. Many of the trials previously conducted in this area have been deemed to be of low quality, in part due to a number of practical constraints. This article provides an overview of established and more innovative clinical trial designs, accompanied by pertinent examples, to highlight how design choices can enhance flexibility and improve efficiency of both resource allocation and participant involvement. Trial designs include individually randomized, cluster randomized, and designs with randomizations at multiple time points and/or addressing several research questions (master protocol studies). Design features include the use of adaptations and considerations for pragmatic or registry-based trials. The appropriate choice of trial design, together with rigorous trial conduct, reporting and analysis, can establish high-quality evidence to advance knowledge in the field. It is anticipated that this article will provide a broad and contemporary introduction to trial designs and will help researchers make informed trial design choices for improved testing of new interventions in eating disorders. PUBLIC SIGNIFICANCE: There is a paucity of high quality randomized controlled trials that have been conducted in eating disorders, highlighting the need to identify where efficiency gains in trial design may be possible to advance the eating disorder research field. We provide an overview of some key trial designs and features which may offer solutions to practical constraints and increase trial efficiency.
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Affiliation(s)
- Elizabeth G Ryan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Caroline X Gao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, Melbourne, Victoria, Australia
| | - Kelsey L Grantham
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Le Thi Phuong Thao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anaïs Charles-Nelson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rhys Bowden
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alan Herschtal
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew B Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrea Phillipou
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, Melbourne, Victoria, Australia
- Department of Psychological Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia
- Department of Mental Health, Austin Health, Melbourne, Victoria, Australia
- Department of Mental Health, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Ho A, Joolaee S, McDonald M, Grant D, White MM, Longstaff H, Palsson E. Navigating Informed Consent Requirements and Expectations in Cluster Randomized Trials: Research Ethics Board Members' and Researchers' Views. Ethics Hum Res 2023; 45:31-45. [PMID: 37988275 DOI: 10.1002/eahr.500189] [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: 11/23/2023]
Abstract
Informed consent is a cornerstone of ethical human research. However, as cluster randomized trials (CRTs) are increasingly popular to evaluate health service interventions, especially as health systems aspire toward the learning health system, questions abound how research teams and research ethics boards (REBs) should navigate intertwining consent and data-use considerations. Methodological and ethical questions include who constitute the participants, whose and what types of consent are necessary, and how data from people who have not consented to participation should be managed to optimize the balance of trust in the research enterprise, respect for persons, the promotion of data integrity, and the pursuit of the public good in the research arena. In this paper, we report the findings and lessons learned from a qualitative study examining how researchers and REB members consider the ethical dimensions of when data can be collected and used in CRTs in the evolving research landscape.
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Affiliation(s)
- Anita Ho
- Associate professor at the University of British Columbia and the University of California
| | - Soodabeh Joolaee
- Research ethics and regulatory specialist at Fraser Health Authority, a researcher at the Center for Health Evaluation & Outcome Sciences at the University of British Columbia, and a professor at the Center for Nursing & Midwifery Research at the Iran University of Medical Sciences
| | - Michael McDonald
- Professor emeritus of applied ethics at the W. Maurice Young Centre for Applied Ethics at the University of British Columbia
| | - Don Grant
- Patient partner at BC SUPPORT (Support for People & Patient-Oriented Research & Trials) Unit
| | | | - Holly Longstaff
- Director of research integration and innovation at Provincial Health Services Authority
| | - Eirikur Palsson
- Associate professor in the Department of Biology at Simon Fraser University
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Hurley JC. Establishing the safety of selective digestive decontamination within the ICU population: a bridge too far? Trials 2023; 24:337. [PMID: 37198636 DOI: 10.1186/s13063-023-07356-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/21/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Infection prevention interventions within the intensive care unit (ICU) setting, whether studied within quality improvement projects or cluster randomized trials (CRT), are seen as low risk and grounded in an ethical imperative. Selective digestive decontamination (SDD) appears highly effective at preventing ICU infections within randomized concurrent control trials (RCCTs) prompting mega-CRTs with mortality as the primary endpoint. FINDINGS Surprisingly, the summary results of RCCTs versus CRTs differ strikingly, being respectively, a 15-percentage-point versus a zero-percentage-point ICU mortality difference between control versus SDD intervention groups. Multiple other discrepancies are equally puzzling and contrary to both prior expectations and the experience within population-based studies of infection prevention interventions using vaccines. Could spillover effects from SDD conflate the RCCT control group event rate differences and represent population harm? Evidence that SDD is fundamentally safe to concurrent non-recipients in ICU populations is absent. A postulated CRT to realize this, the SDD Herd Effects Estimation Trial (SHEET), would require > 100 ICUs to achieve sufficient statistical power to find a two-percentage-point mortality spillover effect. Moreover, as a potentially harmful population-based intervention, SHEET would pose novel and insurmountable ethical issues including who is the research subject; whether informed consent is required and from whom; whether there is equipoise; the benefit versus the risk; considerations of vulnerable groups; and who should be the gatekeeper? CONCLUSION The basis for the mortality difference between control and intervention groups of SDD studies remains unclear. Several paradoxical results are consistent with a spillover effect that would conflate the inference of benefit originating from RCCTs. Moreover, this spillover effect would constitute to herd peril.
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Affiliation(s)
- James C Hurley
- Melbourne Medical School, University of Melbourne, Melbourne, Australia.
- Division of Internal Medicine, Grampians Health Services, Ballarat, VIC, Australia.
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Del Cura-González I, Ariza-Cardiel G, Polentinos-Castro E, López-Rodríguez JA, Sanz-Cuesta T, Barrio-Cortes J, Andreu-Ivorra B, Rodríguez-Barrientos R, Ávila-Tomas JF, Gallego-Ruiz-de-Elvira E, Lozano-Hernández C, Martín-Fernández J. Effectiveness of a game-based educational strategy e-EDUCAGUIA for implementing antimicrobial clinical practice guidelines in family medicine residents in Spain: a randomized clinical trial by cluster. BMC MEDICAL EDUCATION 2022; 22:893. [PMID: 36564769 PMCID: PMC9789537 DOI: 10.1186/s12909-022-03843-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 10/29/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Clinical practice guidelines (CPGs) have teaching potential for health professionals in training clinical reasoning and decision-making, although their use is limited. The objective was to evaluate the effectiveness of a game-based educational strategy e-EDUCAGUIA using simulated clinical scenarios to implement an antimicrobial therapy GPC compared to the usual dissemination strategies to improve the knowledge and skills on decision-making of family medicine residents. Additionally, adherence to e-EDUCAGUIA strategy was assessed. METHODS A multicentre pragmatic cluster-randomized clinical trial was conducted involving seven Teaching Units (TUs) of family medicine in Spain. TUs were randomly allocated to implement an antimicrobial therapy guideline with e-EDUCAGUIA strategy ( intervention) or passive dissemination of the guideline (control). The primary outcome was the differences in means between groups in the score test evaluated knowledge and skills on decision-making at 1 month post intervention. Analysis was made by intention-to-treat and per-protocol analysis. Secondary outcomes were the differences in mean change intrasubject (from the baseline to the 1-month) in the test score, and educational game adherence and usability. Factors associated were analysed using general linear models. Standard errors were constructed using robust methods. RESULTS Two hundred two family medicine residents participated (104 intervention group vs 98 control group). 100 medicine residents performed the post-test at 1 month (45 intervention group vs 55 control group), The between-group difference for the mean test score at 1 month was 11 ( 8.67 to 13.32) and between change intrasubject was 11,9 ( 95% CI 5,9 to 17,9). The effect sizes were 0.88 and 0.75 respectively. In multivariate analysis, for each additional evidence-based medicine training hour there was an increase of 0.28 points (95% CI 0.15-0.42) in primary outcome and in the change intrasubject each year of increase in age was associated with an improvement of 0.37 points and being a woman was associated with a 6.10-point reduction. 48 of the 104 subjects in the intervention group (46.2%, 95% CI: 36.5-55.8%) used the games during the month of the study. Only a greater number of evidence-based medicine training hours was associated with greater adherence to the educational game ( OR 1.11; CI 95% 1.02-1.21). CONCLUSIONS The game-based educational strategy e-EDUCAGUIA shows positive effects on the knowledge and skills on decision making about antimicrobial therapy for clinical decision-making in family medicin residents in the short term, but the dropout was high and results should be interpreted with caution. Adherence to educational games in the absence of specific incentives is moderate. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02210442 . Registered 6 August 2014.
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Affiliation(s)
- Isabel Del Cura-González
- Research Unit, Primary Care Assistance Management, Madrid Health Service Madrid, C/ San Martín de Porres, 6 _ 5ª Planta, 28035, Madrid, Spain.
- Department of Medical Specialties and Public Health, School of Health Sciences, Rey Juan Carlos University, Madrid, Spain.
- Research Network Health Services in Chronic Diseases (REDISSEC) & Research Network RICORS-RICAPP. ISCIII, Madrid, Spain.
- Instituto de Investigación Sanitaria Gregorio Marañon, IiSGM, Madrid, Spain.
| | - Gloria Ariza-Cardiel
- Research Network Health Services in Chronic Diseases (REDISSEC) & Research Network RICORS-RICAPP. ISCIII, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañon, IiSGM, Madrid, Spain
- Multiprofessional Family and Community Care Teaching Unit Madrid, Madrid, Spain
| | - Elena Polentinos-Castro
- Research Unit, Primary Care Assistance Management, Madrid Health Service Madrid, C/ San Martín de Porres, 6 _ 5ª Planta, 28035, Madrid, Spain
- Department of Medical Specialties and Public Health, School of Health Sciences, Rey Juan Carlos University, Madrid, Spain
- Research Network Health Services in Chronic Diseases (REDISSEC) & Research Network RICORS-RICAPP. ISCIII, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañon, IiSGM, Madrid, Spain
| | - Juan A López-Rodríguez
- Research Unit, Primary Care Assistance Management, Madrid Health Service Madrid, C/ San Martín de Porres, 6 _ 5ª Planta, 28035, Madrid, Spain
- Department of Medical Specialties and Public Health, School of Health Sciences, Rey Juan Carlos University, Madrid, Spain
- Research Network Health Services in Chronic Diseases (REDISSEC) & Research Network RICORS-RICAPP. ISCIII, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañon, IiSGM, Madrid, Spain
- General Ricardos Health Center, Primary Care Assistance Management, Madrid Health Service, Madrid, Spain
| | - Teresa Sanz-Cuesta
- Research Unit, Primary Care Assistance Management, Madrid Health Service Madrid, C/ San Martín de Porres, 6 _ 5ª Planta, 28035, Madrid, Spain
- Research Network Health Services in Chronic Diseases (REDISSEC) & Research Network RICORS-RICAPP. ISCIII, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañon, IiSGM, Madrid, Spain
| | - Jaime Barrio-Cortes
- Research Unit, Primary Care Assistance Management, Madrid Health Service Madrid, C/ San Martín de Porres, 6 _ 5ª Planta, 28035, Madrid, Spain
- Primary Health Care Research and Innovation Foundation. FIIBAP, Madrid, Spain
- Universidad Camilo José Cela, Madrid, Spain
| | - Blanca Andreu-Ivorra
- Preventive Medicine Unit, Alcorcon Foundation University Hospital, Alcorcón, Madrid Health Service, Madrid, Spain
| | - Ricardo Rodríguez-Barrientos
- Research Unit, Primary Care Assistance Management, Madrid Health Service Madrid, C/ San Martín de Porres, 6 _ 5ª Planta, 28035, Madrid, Spain
- Research Network Health Services in Chronic Diseases (REDISSEC) & Research Network RICORS-RICAPP. ISCIII, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañon, IiSGM, Madrid, Spain
| | - José F Ávila-Tomas
- Santa Isabel Health Center, Primary Care Assistance Management, Madrid Health Service Leganes, Madrid, Spain
| | - Elisa Gallego-Ruiz-de-Elvira
- Servicio de Medicina Preventiva, Hospital Infantil Universitario Niño Jesús, Madrid Health Service, Madrid, Spain
| | - Cristina Lozano-Hernández
- Research Unit, Primary Care Assistance Management, Madrid Health Service Madrid, C/ San Martín de Porres, 6 _ 5ª Planta, 28035, Madrid, Spain
- Research Network Health Services in Chronic Diseases (REDISSEC) & Research Network RICORS-RICAPP. ISCIII, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañon, IiSGM, Madrid, Spain
- Primary Health Care Research and Innovation Foundation. FIIBAP, Madrid, Spain
| | - Jesús Martín-Fernández
- Department of Medical Specialties and Public Health, School of Health Sciences, Rey Juan Carlos University, Madrid, Spain
- Research Network Health Services in Chronic Diseases (REDISSEC) & Research Network RICORS-RICAPP. ISCIII, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañon, IiSGM, Madrid, Spain
- Multiprofessional Family and Community Care Teaching Unit Madrid, Madrid, Spain
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Sewankambo NK, Kutyabami P. Empowering local research ethics review of antibacterial mass administration research. Infect Dis Poverty 2022; 11:103. [PMID: 36171611 PMCID: PMC9516823 DOI: 10.1186/s40249-022-01031-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 09/14/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Recent studies using mass drug administration (MDA) of antibiotics to entire communities have focused global attention on the unique ethical challenges of MDA of antibiotics in research and public health interventions. However, there is no specific guidance for Research Ethics Committees (RECs) or Institutional Review Boards (IRBs) to review such trials. We surveyed the literature to identify the unique ethical challenges and to strengthen the competencies of RECs or IRBs in low- and middle-income countries (LMICs) in their ethical reviews of these trials. METHODS We employed a desk review. We searched PubMed, Web of Science, and Google Scholar, combining terms for "mass drug administration" with terms for "research ethics committees," "institutional review boards," and "ethics." We reviewed citations of search results to retrieve additional articles. Only articles published and indexed in the above databases up to 6 January 2022 in English were included. Abstracts (without full articles), books and articles that had exclusive veterinary and environmental focus were excluded. We synthesized the literature to identify particularly challenging ethical issues relevant to antibacterial MDA trials in LMICs. RESULTS The most challenging ethical issues can be categorised into four broad domains: determining the social value of MDA, assessing risks and benefits, engaging all stakeholders meaningfully, and study design-related ethical challenges. These four domains interact and impact each other. Together, they reveal the need for RECs/IRBs to review MDA studies through a broader lens than that of clinical trials per se. From our findings, we propose a framework to guide the RECs and IRBs in LMICs to perform the initial and continuing review of antibiotic MDA trials. We also recommend strengthening the competencies of LMIC RECs or IRBs through ongoing training and collaboration with RECs or IRBs from high-income countries. CONCLUSIONS REC/IRB review of research using MDA of antibiotics plays a critical role in assuring the ethical conduct of MDA studies. Local RECs/IRBs should be empowered to review MDA studies comprehensively and competently in order to advance scientific knowledge about MDA and promote improved global health.
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Affiliation(s)
- Nelson K Sewankambo
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda.
| | - Paul Kutyabami
- Department of Pharmacy, School of Health Sciences, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
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Chua JYX, Shorey S. Effectiveness of mobile application-based perinatal interventions in improving parenting outcomes: A systematic review. Midwifery 2022; 114:103457. [PMID: 35985142 PMCID: PMC9364944 DOI: 10.1016/j.midw.2022.103457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 07/25/2022] [Accepted: 08/09/2022] [Indexed: 11/24/2022]
Abstract
Objective Parents face many challenges during the perinatal period and are at risk for mental health issues, especially during the current coronavirus (COVID-19) pandemic. Mobile application-based interventions can help parents to improve their psychosocial well-being in a convenient and accessible manner. This review aims to examine the effectiveness of mobile application-based perinatal interventions in improving parenting self-efficacy, anxiety, and depression (primary outcomes), as well as stress, social support, and parent-child bonding (secondary outcomes) among parents. Methods Seven electronic databases (PubMed, Embase, CINAHL, PsycINFO, Web of Science, Scopus, and ProQuest Thesis and Dissertations) were searched from their respective inception dates until August 2021. The Cochrane Risk of Bias-2 tool was used to conduct quality appraisals. Results were narratively synthesized due to the high heterogeneity of intervention and participant types. Findings A total of 6164 articles were retrieved from the seven electronic databases and citation searching. After excluding duplicate records and irrelevant titles/abstracts, 105 full texts were examined. Full-text screening excluded another 93 articles, leaving 12 included studies in this review. All studies were rated as having some concerns or a high overall risk of bias. Mobile application-based interventions were found to be feasible and promising in improving parents’ overall well-being post-intervention during the perinatal period. Further research would be needed to determine their long-term effects. Key conclusions and implications for practice Parental well-being was shown to improve using the following intervention components: educational resources on perinatal and infant care, psychotherapy, and support from peers and healthcare professionals. Hence, future interventions could aim to include these components and evaluate all inter-related parenting outcomes (parenting self-efficacy, stress, anxiety, depression, social support, and parent-child bonding). Parents could be provided with experiential learning exposure by using computer animations and virtual reality. Future research could be conducted on more fathers and parents from varied geographical regions.
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Affiliation(s)
- Joelle Yan Xin Chua
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive 117597, Singapore
| | - Shefaly Shorey
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive 117597, Singapore.
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Patterson CG, Leland NE, Mormer E, Palmer CV. Alternative Designs for Testing Speech, Language, and Hearing Interventions: Cluster-Randomized Trials and Stepped-Wedge Designs. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2022; 65:2677-2690. [PMID: 35858257 DOI: 10.1044/2022_jslhr-21-00522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE Individual-randomized trials are the gold standard for testing the efficacy and effectiveness of drugs, devices, and behavioral interventions. Health care delivery, educational, and programmatic interventions are often complex, involving multiple levels of change and measurement precluding individual randomization for testing. Cluster-randomized trials and cluster-randomized stepped-wedge trials are alternatives where the intervention is allocated at the group level, such as a clinic or a school, and the outcomes are measured at the person level. These designs are introduced along with the statistical implications of similarities among individuals within the same cluster. We also illustrate the parameters that have the most impact on the likelihood of detecting intervention effects, which must be considered when planning these trials. CONCLUSION Cluster-randomized and stepped-wedge designs should be considered by researchers as experimental alternatives to individual-randomized trials when testing speech, language, and hearing care interventions in real-world settings.
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Affiliation(s)
- Charity G Patterson
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, PA
- School of Health and Rehabilitation Sciences Data Center, University of Pittsburgh, PA
| | - Natalie E Leland
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, PA
| | - Elaine Mormer
- Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, PA
| | - Catherine V Palmer
- Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, PA
- Department of Otolaryngology, School of Medicine, University of Pittsburgh, PA
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Knoop J, Dekker J, van Dongen JM, van der Leeden M, de Rooij M, Peter WF, de Joode W, van Bodegom-Vos L, Lopuhaä N, Bennell KL, Lems WF, van der Esch M, Vliet Vlieland TP, Ostelo RW. Stratified exercise therapy does not improve outcomes compared with usual exercise therapy in people with knee osteoarthritis (OCTOPuS study): a cluster randomised trial. J Physiother 2022; 68:182-190. [PMID: 35760724 DOI: 10.1016/j.jphys.2022.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/28/2022] [Accepted: 06/07/2022] [Indexed: 10/17/2022] Open
Abstract
QUESTION In people with knee osteoarthritis, how much more effective is stratified exercise therapy that distinguishes three subgroups (high muscle strength subgroup, low muscle strength subgroup, obesity subgroup) in reducing knee pain and improving physical function than usual exercise therapy? DESIGN Pragmatic cluster randomised controlled trial in a primary care setting. PARTICIPANTS A total of 335 people with knee osteoarthritis: 153 in an experimental arm and 182 in a control arm. INTERVENTION Physiotherapy practices were randomised into an experimental arm providing stratified exercise therapy (supplemented by a dietary intervention from a dietician for the obesity subgroup) or a control arm providing usual, non-stratified exercise therapy. OUTCOME MEASURES Primary outcomes were knee pain severity (numerical rating scale for pain, 0 to 10) and physical function (Knee Injury and Osteoarthritis Outcome Score subscale activities of daily living, 0 to 100). Measurements were performed at baseline, 3 months (primary endpoint) and 6 and 12 months (follow-up). Intention-to-treat, multilevel, regression analysis was performed. RESULTS Negligible differences were found between the experimental and control groups in knee pain (mean adjusted difference 0.2, 95% CI -0.4 to 0.7) and physical function (-0.8, 95% CI -4.3 to 2.6) at 3 months. Similar effects between groups were also found for each subgroup separately, as well as at other time points and for nearly all secondary outcome measures. CONCLUSION This pragmatic trial demonstrated no added value regarding clinical outcomes of the model of stratified exercise therapy compared with usual exercise therapy. This could be attributed to the experimental arm therapists facing difficulty in effectively applying the model (especially in the obesity subgroup) and to elements of stratified exercise therapy possibly being applied in the control arm. REGISTRATION Netherlands National Trial Register NL7463.
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Affiliation(s)
- Jesper Knoop
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.
| | - Joost Dekker
- Department of Rehabilitation Medicine, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Johanna M van Dongen
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Marike van der Leeden
- Department of Rehabilitation Medicine, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands; Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, Netherlands
| | - Mariette de Rooij
- Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, Netherlands
| | - Wilfred Fh Peter
- Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, Netherlands; Department of Orthopaedics, Leiden University Medical Center, Leiden, Netherlands
| | - Willemijn de Joode
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | | | - Kim L Bennell
- Department of Physiotherapy, School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Willem F Lems
- Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, Netherlands; Amsterdam UMC, location VUmc, Department of Rheumatology, Amsterdam, Netherlands
| | - Martin van der Esch
- Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, Netherlands; Center of Expertise Urban Vitality, Health Faculty, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | | | - Raymond Wjg Ostelo
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands; Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands; Department of Epidemiology and Data Science, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
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10
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Berner-Rodoreda A, McMahon S, Eyal N, Hossain P, Rabbani A, Barua M, Sarker M, Metta E, Mmbaga E, Leshabari M, Wikler D, Bärnighausen T. Consent Requirements for Testing Health Policies: An Intercontinental Comparison of Expert Opinions. J Empir Res Hum Res Ethics 2022; 17:346-361. [PMID: 35617114 PMCID: PMC9136368 DOI: 10.1177/15562646221076764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Individual informed consent is a central requirement for clinical research on
human subjects, yet whether and how consent requirements should apply to health
policy experiments (HPEs) remains unclear. HPEs test and evaluate public health
policies prior to implementation. We interviewed 58 health experts in Tanzania,
Bangladesh and Germany on informed consent requirements for HPEs. Health experts
across all countries favored a strong evidence base, prior information to the
affected populations, and individual consent for ‘risky’ HPEs. Differences
pertained to individual risk perception, how and when consent by group
representatives should be obtained and whether HPEs could be treated as health
policies. The study adds to representative consent options for HPEs, yet shows
that more research is needed in this field – particularly in the present
Covid-19 pandemic which has highlighted the need for HPEs nationally and
globally.
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Affiliation(s)
| | - Shannon McMahon
- Heidelberg Institute of Global Health, Heidelberg University, Germany
- Social and Behavioral Interventions, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Nir Eyal
- Department of Health, Behavior, Society and Policy, Rutgers University, Piscataway, USA
- Center for Population-Level Bioethics, New Brunswick, USA
| | - Puspita Hossain
- McMaster University, Hamilton, Canada
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Atonu Rabbani
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
- Department of Economics, University of Dhaka, Dhaka, Bangladesh
| | - Mrittika Barua
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
- Radboud Universiteit, Nijmegen, Netherlands
| | - Malabika Sarker
- Heidelberg Institute of Global Health, Heidelberg University, Germany
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Emmy Metta
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Elia Mmbaga
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Melkizedeck Leshabari
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Daniel Wikler
- Harvard T.H. Chan School of Public Health, Department of Global Health and Population, Boston, USA
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Germany
- Harvard T.H. Chan School of Public Health, Department of Global Health and Population, Boston, USA
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11
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Howarth AR, Estcourt CS, Ashcroft RE, Cassell JA. Building an Opt-Out Model for Service-Level Consent in the Context of New Data Regulations. Public Health Ethics 2022; 15:175-180. [DOI: 10.1093/phe/phab030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
The General Data Protection Regulation (GDPR) was introduced in 2018 to harmonize data privacy and security laws across the European Union (EU). It applies to any organization collecting personal data in the EU. To date, service-level consent has been used as a proportionate approach for clinical trials, which implement low-risk, routine, service-wide interventions for which individual consent is considered inappropriate. In the context of public health research, GDPR now requires that individuals have the option to choose whether their data may be used for research, which presents a challenge when consent has been given by the clinical service and not by individual service users. We report here on development of a pragmatic opt-out solution to this consent paradox in the context of a partner notification intervention trial in sexual health clinics in the UK. Our approach supports the individual’s right to withhold their data from trial analysis while routinely offering the same care to all patients.
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12
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Klitzman RL. Understanding Ethical Challenges in Medical Education Research. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:18-21. [PMID: 34292193 DOI: 10.1097/acm.0000000000004253] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Rapidly advancing biomedical and electronic technologies, ongoing health disparities, and new online educational modalities are all changing medicine and medical education. As medical training continues to evolve, research is increasingly critical to help improve it, but medical education research can pose unique ethical challenges. As research participants, medical trainees may face several risks and in many ways constitute a vulnerable group. In this commentary, the author examines several of the ethical challenges involved in medical education research, including confidentiality and the risk of stigma; the need for equity, diversity, and inclusion; genetic testing of students; clustered randomized trials of training programs; and questions about quality improvement activities. The author offers guidance for navigating these ethical challenges, including the importance of engaging with institutional review boards. Academic medical institutions should educate and work closely with faculty to ensure that all research adheres to appropriate ethical guidelines and regulations and should provide instruction about the ethics of medical education research to establish a strong foundation for the future of the field. Research on medical education will become increasingly important. Given the potential sensitivity of the data collected in such research, investigators must understand and address potential ethical challenges as carefully as possible.
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Affiliation(s)
- Robert L Klitzman
- R.L. Klitzman is professor of psychiatry and director, Masters of Bioethics Program, Columbia University, New York, New York
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13
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Nix HP, Weijer C, Brehaut JC, Forster D, Goldstein CE, Taljaard M. Informed consent in cluster randomised trials: a guide for the perplexed. BMJ Open 2021; 11:e054213. [PMID: 34580104 PMCID: PMC8477335 DOI: 10.1136/bmjopen-2021-054213] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/15/2021] [Indexed: 11/19/2022] Open
Abstract
In a cluster randomised trial (CRT), intact groups-such as communities, clinics or schools-are randomised to the study intervention or control conditions. The issue of informed consent in CRTs has been particularly challenging for researchers and research ethics committees. Some argue that cluster randomisation is a reason not to seek informed consent from research participants. In fact, systematic reviews have found that, relative to individually randomised trials, CRTs are associated with an increased likelihood of inadequate reporting of consent procedures and inappropriate use of waivers of consent. The objective of this paper is to clarify this confusion by providing a practical and useful framework to guide researchers and research ethics committees through consent issues in CRTs. In CRTs, it is the unit of intervention-not the unit of randomisation-that drives informed consent issues. We explicate a three-step framework for thinking through informed consent in CRTs: (1) identify research participants, (2) identify the study element(s) to which research participants are exposed, and (3) determine if a waiver of consent is appropriate for each study element. We then apply our framework to examples of CRTs of cluster-level, professional-level and individual-level interventions, and provide key lessons on informed consent for each type of CRT.
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Affiliation(s)
- Hayden P Nix
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Charles Weijer
- Department of Philosophy, Western University, London, Ontario, Canada
- Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada
- Department of Medicine, Western University, London, Ontario, Canada
| | - Jamie C Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - David Forster
- Institutional Review Board, WIRB-Copernicus Group Inc, Puyallup, Washington, USA
| | - Cory E Goldstein
- Department of Philosophy, Western University, London, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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14
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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.
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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
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15
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The role and challenges of cluster randomised trials for global health. LANCET GLOBAL HEALTH 2021; 9:e701-e710. [PMID: 33865475 DOI: 10.1016/s2214-109x(20)30541-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022]
Abstract
Evaluating whether an intervention works when trialled in groups of individuals can pose complex challenges for clinical research. Cluster randomised controlled trials involve the random allocation of groups or clusters of individuals to receive an intervention, and they are commonly used in global health research. In this paper, we describe the potential reasons for the increasing popularity of cluster trials in low-income and middle-income countries. We also draw on key areas of global health research for an assessment of common trial planning practices, and we address their methodological shortcomings and pitfalls. Lastly, we discuss alternative approaches for population-level intervention trials that could be useful for research undertaken in low-income and middle-income countries for situations in which the use of cluster randomisation might not be appropriate.
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16
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Abstract
Today's clinical practice relies on the application of well-designed clinical research, the gold standard test of an intervention being the randomized controlled trial. Principles of the randomized control trial include emphasis on the principal research question, randomization, blinding; definitions of outcome measures, of inclusion and exclusion criteria, and of co-morbid and confounding factors; enrolling an adequate sample size; planning data management and analysis; preventing challenges to trial integrity such as drop-out, drop-in, and bias. The application of pre-trial planning is stressed to ensure the proper application of epidemiological principles resulting in clinical studies that are feasible and generalizable. In addition, funding strategies and trial team composition are discussed.
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17
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Giblin L, Vousden N, Nathan H, Gidiri F, Goudar S, Charantimath U, Sandall J, Seed PT, Chappell LC, Shennan AH. Effect of the CRADLE vital signs alert device intervention on referrals for obstetric haemorrhage in low-middle income countries: a secondary analysis of a stepped- wedge cluster-randomised control trial. BMC Pregnancy Childbirth 2021; 21:317. [PMID: 33882864 PMCID: PMC8061003 DOI: 10.1186/s12884-021-03796-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/16/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Obstetric haemorrhage is the leading cause of maternal death worldwide, 99% of which occur in low and middle income countries. The majority of deaths and adverse events are associated with delays in identifying compromise and escalating care. Management of severely compromised pregnant women may require transfer to tertiary centres for specialised treatment, therefore early recognition is vital for efficient management. The CRADLE vital signs alert device accurately measures blood pressure and heart rate, calculates the shock index (heart rate divided by systolic blood pressure) and alerts the user to compromise through a traffic light system reflecting previously validated shock index thresholds. METHODS This is a planned secondary analysis of data from the CRADLE-3 trial from ten clusters across Africa, India and Haiti where the device and training package were randomly introduced. Referral data were prospectively collected for a 4-week period before, and a 4-week period 3 months after implementation. Referrals from primary or secondary care facilities to higher level care for any cause were recorded. The denominator was the number of women seen for maternity care in these facilities. RESULTS Between April 1 2016 and Nov 30th, 2017 536,223 women attended maternity care facilities. Overall, 3.7% (n = 2784/74,828) of women seen in peripheral maternity facilities were referred to higher level care in the control period compared to 4.4% (n = 3212/73,371) in the intervention period (OR 0.89; 0.39-2.05) (data for nine sites that were able to collect denominator). Of these 0.29% (n = 212) pre-intervention and 0.16% (n = 120) post-intervention were referred to higher-level facilities for maternal haemorrhage. Although overall referrals did not significantly reduce there was a significant reduction in referrals for obstetric haemorrhage (OR 0.56 (0.39-0.65) following introduction of the device with homogeneity (i-squared 26.1) between sites. There was no increase in any bleeding-related morbidity (maternal death or emergency hysterectomy). CONCLUSIONS Referrals for obstetric haemorrhage reduced following implementation of the CRADLE Vital Signs Alert Device, occurring without an increase in maternal death or emergency hysterectomy. This demonstrates the potential benefit of shock index in management pathways for obstetric haemorrhage and targeting limited resources in low- middle- income settings. TRIAL REGISTRATION This study is registered with the ISRCTN registry, number ISRCTN41244132 (02/02/2016).
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Affiliation(s)
- Lucie Giblin
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Nicola Vousden
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Hannah Nathan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Francis Gidiri
- Department of Obstetrics and Gynaecology, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Shivaprasad Goudar
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Umesh Charantimath
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Paul T Seed
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 7EH, UK.
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Rationale, Methodological Quality, and Reporting of Cluster-Randomized Controlled Trials in Critical Care Medicine: A Systematic Review. Crit Care Med 2021; 49:977-987. [PMID: 33591020 DOI: 10.1097/ccm.0000000000004885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Compared with individual-patient randomized controlled trials, cluster randomized controlled trials have unique methodological and ethical considerations. We evaluated the rationale, methodological quality, and reporting of cluster randomized controlled trials in critical care studies. DATA SOURCES Systematic searches of Medline, Embase, and Cochrane Central Register were performed. STUDY SELECTION We included all cluster randomized controlled trials conducted in adult, pediatric, or neonatal critical care units from January 2005 to September 2019. DATA EXTRACTION Two reviewers independently screened citations, reviewed full texts, protocols, and supplements of potentially eligible studies, abstracted data, and assessed methodology of included studies. DATA SYNTHESIS From 1,902 citations, 59 cluster randomized controlled trials met criteria. Most focused on quality improvement (24, 41%), antimicrobial therapy (9, 15%), or infection control (9, 15%) interventions. Designs included parallel-group (25, 42%), crossover (21, 36%), and stepped-wedge (13, 22%). Concealment of allocation was reported in 21 studies (36%). Thirteen studies (22%) reported at least one method of blinding. The median total sample size was 1,660 patients (interquartile range, 813-4,295); the median number of clusters was 12 (interquartile range, 5-24); and the median patients per cluster was 141 (interquartile range, 54-452). Sample size calculations were reported in 90% of trials, but only 54% met Consolidated Standards of Reporting Trials guidance for sample size reporting. Twenty-seven of the studies (46%) identified a fixed number of available clusters prior to trial commencement, and only nine (15%) prespecified both the number of clusters and patients required to detect the expected effect size. Overall, 36 trials (68%) achieved the total prespecified sample size. When analyzing data, 44 studies (75%) appropriately adjusted for clustering when analyzing the primary outcome. Only 12 (20%) reported an intracluster coefficient (median 0.047 [interquartile range, 0.01-0.13]). CONCLUSIONS Cluster randomized controlled trials in critical care typically involve a small and fixed number of relatively large clusters. The reporting of key methodological aspects of these trials is often inadequate.
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Nicholls SG, Carroll K, Weijer C, Goldstein CE, Brehaut J, Sood MM, Al-Jaishi A, Basile E, Grimshaw JM, Garg AX, Taljaard M. Ethical Issues in the Design and Conduct of Pragmatic Cluster Randomized Trials in Hemodialysis Care: An Interview Study With Key Stakeholders. Can J Kidney Health Dis 2020; 7:2054358120964119. [PMID: 33194212 PMCID: PMC7597560 DOI: 10.1177/2054358120964119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Pragmatic cluster randomized trials (CRTs) offer an opportunity to improve health care by answering important questions about the comparative effectiveness of treatments using a trial design that can be embedded in routine care. There is a lack of empirical research that addresses ethical issues generated by pragmatic CRTs in hemodialysis. OBJECTIVE To identify stakeholder perceptions of ethical issues in pragmatic CRTs conducted in hemodialysis. DESIGN Qualitative study using semi-structured interviews. SETTING In-person or telephone interviews with an international group of stakeholders. PARTICIPANTS Stakeholders (clinical investigators, methodologists, ethicists and research ethics committee members, and other knowledge users) who had been involved in the design or conduct of a pragmatic individual patient or cluster randomized trial in hemodialysis, or their role would require them to review and evaluate pragmatic CRTs in hemodialysis. METHODS Interviews were conducted in-person or over the telephone and were audio-recorded with consent. Recorded interviews were transcribed verbatim prior to analysis. Transcripts and field notes were analyzed using a thematic analysis approach. RESULTS Sixteen interviews were conducted with 19 individuals. Interviewees were largely drawn from North America (84%) and were predominantly clinical investigators (42%). Six themes were identified in which pragmatic CRTs in hemodialysis raise ethical issues: (1) patients treated with hemodialysis as a vulnerable population, (2) appropriate approaches to informed consent, (3) research burdens, (4) roles and responsibilities of gatekeepers, (5) inequities in access to research, and (6) advocacy for patient-centered research and outcomes. LIMITATIONS Participants were largely from North America and did not include research staff, who may have differing perspectives. CONCLUSIONS The six themes reflect concerns relating to individual rights, but also the need to consider population-level issues. To date, concerns regarding inequity of access to research and the need for patient-centered research have received less coverage than other, well-known, issues such as consent. Pragmatic CRTs offer a potential approach to address equity concerns and we suggest future ethical analyses and guidance for pragmatic CRTs in hemodialysis embed equity considerations within them. We further note the potential for the co-creation of health data infrastructure with patients which would aid care but also facilitate patient-centered research. These present results will inform planned future guidance in relation to the ethical design and conduct of pragmatic CRTs in hemodialysis. TRIAL REGISTRATION Registration is not applicable as this is a qualitative study.
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Affiliation(s)
- Stuart G. Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Charles Weijer
- Department of Philosophy, Western University, London, Canada
- Department of Medicine, Western University, London, Canada
- Department of Epidemiology and Biostatistics, Western University, London, Canada
| | | | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Manish M. Sood
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Jindal Research Chair for the Prevention of Kidney Disease, The Ottawa Hospital, Ottawa, Canada
- Institute for Clinical Evaluative Sciences, Ontario, Canada
| | - Ahmed Al-Jaishi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Erika Basile
- Research Ethics and Compliance, Western University, London, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Amit X. Garg
- Department of Epidemiology and Biostatistics, Western University, London, Canada
- Institute for Clinical Evaluative Sciences, Ontario, Canada
- Division of Nephrology- Department of Medicine, Western University, London, Canada
- Nephrology, London Health Sciences Centre, London, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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20
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Rogers A, Craig G, Flynn A, Mackenzie I, MacDonald T, Doney A. Cluster randomised trials of prescribing policy: an ethical approach to generating drug safety evidence? A discussion of the ethical application of a new research method. Trials 2020; 21:477. [PMID: 32498697 PMCID: PMC7273660 DOI: 10.1186/s13063-020-04357-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 04/28/2020] [Indexed: 11/10/2022] Open
Abstract
For most chronic medical conditions, multiple medications are available and prescribers often have limited evidence about which therapy is likely to be the most effective and safe for an individual patient. As many patients are exposed every day to medicines that may be less effective than available alternatives, this is of public health importance. Cluster randomised trials of prescribing policy offer an opportunity to rapidly obtain evidence of comparative effectiveness and safety. These trials can pose a low risk to patients and cause minimal disruption to usual care. Despite the potential scientific value of this approach, there remain valid concerns about consent, medication switching and the use of routinely collected data in research. We discuss these concerns with reference to an ongoing pilot study (Evaluating Diuretics in Normal Care (EVIDENCE) - a cluster randomised evaluation of hypertension prescribing policy, ISRCTN 46635087, registered 11 August 2017).
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Affiliation(s)
- Amy Rogers
- MEMO Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK.
| | - Gillian Craig
- Health and Clinical Services, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
- Department of Physics, University of Strathclyde, 107 Rottenrow East, Glasgow, G4 0NG, UK
| | - Angela Flynn
- MEMO Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Isla Mackenzie
- MEMO Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Thomas MacDonald
- MEMO Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Alexander Doney
- MEMO Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
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21
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Choko AT, Roshandel G, Conserve DF, Corbett EL, Fielding K, Hemming K, Malekzadeh R, Weijer C. Ethical issues in cluster randomized trials conducted in low- and middle-income countries: an analysis of two case studies. Trials 2020; 21:314. [PMID: 32295604 PMCID: PMC7161096 DOI: 10.1186/s13063-020-04269-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Cluster randomized trials are common in health research in low- and middle-income countries raising issues that challenge interpretation of standard ethical guidelines. While the Ottawa Statement on the ethical design and conduct of cluster randomized trials provides guidance for researchers and research ethics committees, it does not explicitly focus on low- and middle-income settings. MAIN BODY In this paper, we use the lens of the Ottawa Statement to analyze two cluster randomized trials conducted in low- and middle-income settings in order to identify gaps or ethical issues requiring further analysis and guidance. The PolyIran trial was a parallel-arm, cluster trial examining the effectiveness of a polypill for prevention of cardiovascular disease in Golestan province, Iran. The PASTAL trial was an adaptive, multistage, parallel-arm, cluster trial evaluating the effect of incentives for human immunodeficiency virus self-testing and follow-up on male partners of pregnant women in Malawi. Through an in-depth case analysis of these two studies we highlight several issues in need of further exploration. First, standards for verbal consent and waivers of consent require methods for operationalization if they are to be employed consistently. Second, the appropriate choice of a control arm remains contentious. Particularly in the case of implementation interventions, locally available care is required as the comparator to address questions of comparative effectiveness. However, locally available care might be lower than standards set out in national guidelines. Third, while the need for access to effective interventions post-trial is widely recognized, it is often not possible to guarantee this upfront. Clarity on what is required of researchers and sponsors is needed. Fourth, there is a pressing need for ethics education and capacity building regarding cluster randomized trials in these settings. CONCLUSION We identify four issues in cluster randomized trials conducted in low- and middle-income countries for which further ethical analysis and guidance is required.
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Affiliation(s)
- Augustine T Choko
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Gholamreza Roshandel
- Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran
| | - Donaldson F Conserve
- Department of Health Promotion, Education and Behaviour, University of South Carolina, Columbia, USA
| | - Elizabeth L Corbett
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Reza Malekzadeh
- Digestive Disease Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, London, Canada.
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22
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Estcourt CS, Howarth AR, Copas A, Low N, Mapp F, Woode Owusu M, Flowers P, Roberts T, Mercer CH, Wayal S, Symonds M, Nandwani R, Saunders J, Johnson AM, Pothoulaki M, Althaus C, Pickering K, McKinnon T, Brice S, Comer A, Tostevin A, Ogwulu CD, Vojt G, Cassell JA. Accelerated partner therapy (APT) partner notification for people with Chlamydia trachomatis: protocol for the Limiting Undetected Sexually Transmitted infections to RedUce Morbidity (LUSTRUM) APT cross-over cluster randomised controlled trial. BMJ Open 2020; 10:e034806. [PMID: 32229523 PMCID: PMC7170609 DOI: 10.1136/bmjopen-2019-034806] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Partner notification (PN) is a process aiming to identify, test and treat the sex partners of people (index patients) with sexually transmitted infections (STIs). Accelerated partner therapy (APT) is a PN method whereby healthcare professionals assess sex partners, by telephone consultation, before giving the index patient antibiotics and STI self-sampling kits to deliver to their sex partner(s). The Limiting Undetected Sexually Transmitted infections to RedUce Morbidity programme aims to determine the effectiveness of APT in heterosexual women and men with chlamydia and determine whether APT could affect Chlamydia trachomatis transmission at population level. METHODS AND ANALYSIS This protocol describes a cross-over cluster randomised controlled trial of APT, offered as an additional PN method, compared with standard PN. The trial is accompanied by an economic evaluation, transmission dynamic modelling and a qualitative process evaluation involving patients, partners and healthcare professionals. Clusters are 17 sexual health clinics in areas of England and Scotland with contrasting patient demographics. We will recruit 5440 heterosexual women and men with chlamydia, aged ≥16 years.The primary outcome is the proportion of index patients testing positive for C. trachomatis 12-16 weeks after the PN consultation. Secondary outcomes include: proportion of sex partners treated; cost effectiveness; model-predicted chlamydia prevalence; experiences of APT.The primary outcome analysis will be by intention-to-treat, fitting random effects logistic regression models that account for clustering of index patients within clinics and trial periods. The transmission dynamic model will be used to predict change in chlamydia prevalence following APT. The economic evaluation will use mathematical modelling outputs, taking a health service perspective. Qualitative data will be analysed using interpretative phenomenological analysis and framework analysis. ETHICS AND DISSEMINATION This protocol received ethical approval from London-Chelsea Research Ethics Committee (18/LO/0773). Findings will be published with open access licences. TRIAL REGISTRATION NUMBER ISRCTN15996256.
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Affiliation(s)
- Claudia S Estcourt
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | | | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Fiona Mapp
- Institute for Global Health, UCL, London, UK
| | | | - Paul Flowers
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Tracy Roberts
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | - Sonali Wayal
- Institute for Global Health, UCL, London, UK
- Development Media International CIC, London, Greater London, UK
| | - Merle Symonds
- Western Sussex Hospitals NHS Foundation Trust, Worthing, West Sussex, UK
| | | | - John Saunders
- Institute for Global Health, UCL, London, UK
- Public Health England, London, UK
| | | | - Maria Pothoulaki
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Christian Althaus
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Karen Pickering
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | - Susannah Brice
- All East Sexual Health, Barts Health NHS Trust, London, UK
| | - Alex Comer
- All East Sexual Health, Barts Health NHS Trust, London, UK
| | | | | | - Gabriele Vojt
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
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23
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The role of data and safety monitoring boards in implementation trials: When are they justified? J Clin Transl Sci 2020; 4:229-232. [PMID: 32695494 PMCID: PMC7348012 DOI: 10.1017/cts.2020.19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The National Institutes of Health requires data and safety monitoring boards (DSMBs) for all phase III clinical trials. The National Heart, Lung and Blood Institute requires DSMBs for all clinical trials involving more than one site and those involving cooperative agreements and contracts. These policies have resulted in the establishment of DSMBs for many implementation trials, with little consideration regarding the appropriateness of DSMBs and/or key adaptations needed by DSMBs to monitor data quality and participant safety. In this perspective, we review the unique features of implementation trials and reflect on key questions regarding the justification for DSMBs and their potential role and monitoring targets within implementation trials.
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24
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Nsangi A, Semakula D, Oxman AD, Austvoll-Dahlgren A, Oxman M, Rosenbaum S, Morelli A, Glenton C, Lewin S, Kaseje M, Chalmers I, Fretheim A, Ding Y, Sewankambo NK. Effects of the Informed Health Choices primary school intervention on the ability of children in Uganda to assess the reliability of claims about treatment effects, 1-year follow-up: a cluster-randomised trial. Trials 2020; 21:27. [PMID: 31907013 PMCID: PMC6945419 DOI: 10.1186/s13063-019-3960-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 12/04/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION We evaluated an intervention designed to teach 10- to 12-year-old primary school children to assess claims about the effects of treatments (any action intended to maintain or improve health). We report outcomes measured 1 year after the intervention. METHODS In this cluster-randomised trial, we included primary schools in the central region of Uganda that taught year 5 children (aged 10 to 12 years). We randomly allocated a representative sample of eligible schools to either an intervention or control group. Intervention schools received the Informed Health Choices primary school resources (textbooks, exercise books and a teachers' guide). The primary outcomes, measured at the end of the school term and again after 1 year, were the mean score on a test with two multiple-choice questions for each of the 12 concepts and the proportion of children with passing scores. RESULTS We assessed 2960 schools for eligibility; 2029 were eligible, and a random sample of 170 were invited to recruitment meetings. After recruitment meetings, 120 eligible schools consented and were randomly assigned to either the intervention group (n = 60 schools; 76 teachers and 6383 children) or the control group (n = 60 schools; 67 teachers and 4430 children). After 1 year, the mean score in the multiple-choice test for the intervention schools was 68.7% compared with 53.0% for the control schools (adjusted mean difference 16.7%; 95% CI, 13.9 to 19.5; P < 0.00001). In the intervention schools, 3160 (80.1%) of 3943 children who completed the test after 1 year achieved a predetermined passing score (≥ 13 of 24 correct answers) compared with 1464 (51.5%) of 2844 children in the control schools (adjusted difference, 39.5%; 95% CI, 29.9 to 47.5). CONCLUSION Use of the learning resources led to a large improvement in the ability of children to assess claims, which was sustained for at least 1 year. TRIAL REGISTRATION Pan African Clinical Trial Registry (www.pactr.org), PACTR201606001679337. Registered on 13 June 2016.
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Affiliation(s)
- Allen Nsangi
- College of Health Sciences, Makerere University, Kampala, Uganda
- University of Oslo, Oslo, Norway
| | - Daniel Semakula
- College of Health Sciences, Makerere University, Kampala, Uganda
- University of Oslo, Oslo, Norway
| | - Andrew D. Oxman
- University of Oslo, Oslo, Norway
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Postboks 222 Skøyen, 0213 Oslo, Norway
| | - Astrid Austvoll-Dahlgren
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Postboks 222 Skøyen, 0213 Oslo, Norway
| | - Matt Oxman
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Postboks 222 Skøyen, 0213 Oslo, Norway
| | - Sarah Rosenbaum
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Postboks 222 Skøyen, 0213 Oslo, Norway
| | | | - Claire Glenton
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Postboks 222 Skøyen, 0213 Oslo, Norway
| | - Simon Lewin
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Postboks 222 Skøyen, 0213 Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Margaret Kaseje
- Tropical Institute of Community Health & Development, Kisumu, Kenya
| | | | - Atle Fretheim
- University of Oslo, Oslo, Norway
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Postboks 222 Skøyen, 0213 Oslo, Norway
| | - Yunpeng Ding
- Centre for Informed Health Choices, Norwegian Institute of Public Health, Postboks 222 Skøyen, 0213 Oslo, Norway
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25
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Morain SR, Weinfurt K, Bollinger J, Geller G, Mathews DJ, Sugarman J. Ethics and Collateral Findings in Pragmatic Clinical Trials. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:6-18. [PMID: 31896322 PMCID: PMC7027922 DOI: 10.1080/15265161.2020.1689031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Pragmatic clinical trials (PCTs) offer important benefits, such as generating evidence that is suited to inform real-world health care decisions and increasing research efficiency. However, PCTs also present ethical challenges. One such challenge involves the management of information that emerges in a PCT that is unrelated to the primary research question(s), yet may have implications for the individual patients, clinicians, or health care systems from whom or within which research data were collected. We term these findings as ?pragmatic clinical trial collateral findings,? or ?PCT-CFs?. In this article, we explore the ethical considerations associated with the identification, assessment, and management of PCT-CFs, and how these considerations may vary based upon the attributes of a specific PCT. Our purpose is to map the terrain of PCT-CFs to serve as a foundation for future scholarship as well as policy-making and to facilitate careful deliberation about actual cases as they occur in practice.
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Affiliation(s)
| | | | | | - Gail Geller
- Johns Hopkins University
- Johns Hopkins University School of Medicine
| | - Debra Jh Mathews
- Johns Hopkins University
- Johns Hopkins University School of Medicine
| | - Jeremy Sugarman
- Johns Hopkins University
- Johns Hopkins University School of Medicine
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26
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Kombe MM, Zulu JM, Michelo C, Sandøy IF. Community perspectives on randomisation and fairness in a cluster randomised controlled trial in Zambia. BMC Med Ethics 2019; 20:99. [PMID: 31864351 PMCID: PMC6925446 DOI: 10.1186/s12910-019-0421-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 10/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND One important ethical issue in randomised controlled trials (RCTs) is randomisation. Relatively little is known about how participating individuals and communities understand and perceive central aspects of randomisation such as equality, fairness, transparency and accountability in community-based trials. The aim of this study was to understand and explore study communities' perspectives of the randomisation process in a cluster RCT in rural Zambia studying the effectiveness of different support packages for adolescent girls on early childbearing. METHODS In this explorative study, in-depth semi-structured interviews were carried out in 2018 with 14 individuals who took part in the randomisation process of the Research Initiative to Support the Empowerment of Girls (RISE) project in 2016 and two traditional leaders. Two of the districts where the trial is implemented were purposively selected. Interviews were audio recorded and fully transcribed. Data were analysed by coding and describing emergent themes. RESULTS The understanding of the randomisation process varied. Some respondents understood that randomisation was conducted for research purposes, but most of them did not. They had trouble distinguishing research and aid. Generally, respondents perceived the randomisation process as transparent and fair. However, people thought that there should not have been a "lottery" because they wanted all schools to receive equal or balanced benefits of the interventions. CONCLUSIONS Randomisation was misunderstood by most respondents. Perceived procedural fairness was easier to realize than substantive fairness. Researchers working on Cluster Randomised Controlled Trials (CRCTs) should consider carefully how to explain randomisation.
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Affiliation(s)
- Maureen Mupeta Kombe
- School of Public Health, University of Zambia, Ridgeway Campus, P.O Box 50110, Lusaka, Zambia
| | - Joseph Mumba Zulu
- School of Public Health, University of Zambia, Ridgeway Campus, P.O Box 50110, Lusaka, Zambia
| | - Charles Michelo
- School of Public Health, University of Zambia, Ridgeway Campus, P.O Box 50110, Lusaka, Zambia
| | - Ingvild F. Sandøy
- Centre for Intervention Science in Maternal and Child Health (CISMAC), Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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27
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Knoop J, Dekker J, van der Leeden M, de Rooij M, Peter WFH, van Bodegom-Vos L, van Dongen JM, Lopuhäa N, Bennell KL, Lems WF, van der Esch M, Vliet Vlieland TPM, Ostelo RWJG. Stratified exercise therapy compared with usual care by physical therapists in patients with knee osteoarthritis: A randomized controlled trial protocol (OCTOPuS study). PHYSIOTHERAPY RESEARCH INTERNATIONAL 2019; 25:e1819. [PMID: 31778291 PMCID: PMC7187154 DOI: 10.1002/pri.1819] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/20/2019] [Accepted: 10/03/2019] [Indexed: 12/21/2022]
Abstract
Objectives Knee osteoarthritis (OA) is characterized by its heterogeneity, with large differences in clinical characteristics between patients. Therefore, a stratified approach to exercise therapy, whereby patients are allocated to homogeneous subgroups and receive a stratified, subgroup‐specific intervention, can be expected to optimize current clinical effects. Recently, we developed and pilot tested a model of stratified exercise therapy based on clinically relevant subgroups of knee OA patients that we previously identified. Based on the promising results, it is timely to evaluate the (cost‐)effectiveness of stratified exercise therapy compared with usual, “nonstratified” exercise therapy. Methods A pragmatic cluster randomized controlled trial including economic and process evaluation, comparing stratified exercise therapy with usual care by physical therapists (PTs) in primary care, in a total of 408 patients with clinically diagnosed knee OA. Eligible physical therapy practices are randomized in a 1:2 ratio to provide the experimental (in 204 patients) or control intervention (in 204 patients), respectively. The experimental intervention is a model of stratified exercise therapy consisting of (a) a stratification algorithm that allocates patients to a “high muscle strength subgroup,” “low muscle strength subgroup,” or “obesity subgroup” and (b) subgroup‐specific, protocolized exercise therapy (with an additional dietary intervention from a dietician for the obesity subgroup only). The control intervention will be usual best practice by PTs (i.e., nonstratified exercise therapy). Our primary outcome measures are knee pain severity (Numeric Rating Scale) and physical functioning (Knee Injury and Osteoarthritis Outcome Score subscale daily living). Measurements will be performed at baseline, 3‐month (primary endpoint), 6‐month (questionnaires only), and 12‐month follow‐up, with an additional cost questionnaire at 9 months. Intention‐to‐treat, multilevel, regression analysis comparing stratified versus usual care will be performed. Conclusion This study will demonstrate whether stratified care provided by primary care PTs is effective and cost‐effective compared with usual best practice from PTs.
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Affiliation(s)
- Jesper Knoop
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Joost Dekker
- VU University Medical Center, Department of Rehabilitation Medicine, Amsterdam UMC, Amsterdam, The Netherlands
| | - Marike van der Leeden
- VU University Medical Center, Department of Rehabilitation Medicine, Amsterdam UMC, Amsterdam, The Netherlands.,Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, The Netherlands
| | - Mariëtte de Rooij
- Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, The Netherlands
| | - Wilfred F H Peter
- Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, The Netherlands.,Department of Orthopaedics, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Orthopaedics, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Johanna M van Dongen
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Kim L Bennell
- School of Health Sciences, Department of Physiotherapy, University of Melbourne, Melbourne, Victoria, Australia
| | - Willem F Lems
- VU University Medical Center, Department of Rehabilitation Medicine, Amsterdam UMC, Amsterdam, The Netherlands.,Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, The Netherlands
| | - Martin van der Esch
- Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, The Netherlands.,Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Thea P M Vliet Vlieland
- Department of Orthopaedics, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Raymond W J G Ostelo
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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28
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Parker AG, Markulev C, Rickwood DJ, Mackinnon A, Purcell R, Alvarez-Jimenez M, Yung AR, McGorry P, Hetrick SE, Jorm A. Improving Mood with Physical ACTivity (IMPACT) trial: a cluster randomised controlled trial to determine the effectiveness of a brief physical activity behaviour change intervention on depressive symptoms in young people, compared with psychoeducation, in addition to routine clinical care within youth mental health services-a protocol study. BMJ Open 2019; 9:e034002. [PMID: 31662409 PMCID: PMC6830686 DOI: 10.1136/bmjopen-2019-034002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Depression is highly prevalent and the leading contributor to the burden of disease in young people worldwide, making it an ongoing priority for early intervention. As the current evidence-based interventions of medication and psychological therapy are only modestly effective, there is an urgent need for additional treatment strategies. This paper describes the rationale of the Improving Mood with Physical ACTivity (IMPACT) trial. The primary aim of the IMPACT trial is to determine the effectiveness of a physical activity intervention compared with psychoeducation, in addition to routine clinical care, on depressive symptoms in young people. Additional aims are to evaluate the intervention effects on anxiety and functional outcomes and examine whether changes in physical activity mediate improvements in depressive symptoms. METHODS AND ANALYSIS The study is being conducted in six youth mental health services across Australia and is using a parallel-group, two-arm, cluster randomised controlled trial design, with randomisation occurring at the clinician level. Participants aged between 12 years and 25 years with moderate to severe levels of depression are randomised to receive, in addition to routine clinical care, either: (1) a physical activity behaviour change intervention or (2) psychoeducation about physical activity. The primary outcome will be change in the Quick Inventory of Depressive Symptomatology, with assessments occurring at baseline, postintervention (end-point) and 6-month follow-up from end-point. Secondary outcome measures will address additional clinical outcomes, functioning and quality of life. IMPACT is to be conducted between May 2014 and December 2019. ETHICS AND DISSEMINATION Ethical approval was obtained from the University of Melbourne Human Research Ethics Committee on 8 June 2014 (HREC 1442228). Trial findings will be published in peer-reviewed journals and presented at conferences. Key messages will also be disseminated by the youth mental health services organisation (headspace National Youth Mental Health Foundation). TRIAL REGISTRATION NUMBER ACTRN12614000772640.
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Affiliation(s)
- Alexandra G Parker
- Institute for Health and Sport, Victoria University, Footscray, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia
| | - Connie Markulev
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia
| | - Debra J Rickwood
- Department of Psychology, University of Canberra, Canberra, Australian Capital Territory, Australia
- headspace, National Youth Mental Health Foundation, Melbourne, Victoria, Australia
| | - Andrew Mackinnon
- School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
- The University of New South Wales, Black Dog Institute, Randwick, New South Wales, Australia
| | - Rosemary Purcell
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia
| | - Mario Alvarez-Jimenez
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia
| | - Alison R Yung
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia
- School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Patrick McGorry
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia
| | - Sarah E Hetrick
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia
- Department of Psychological Medicine, University of Auckland, Auckland, New Zealand
| | - Anthony Jorm
- School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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29
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Tumilty E, Farroni JS. Issues of Justice and Risk: Setting Stopping Criteria in Cluster-Randomized Trials. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:110-111. [PMID: 31557101 DOI: 10.1080/15265161.2019.1654012] [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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30
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Binik A. Delaying and withholding interventions: ethics and the stepped wedge trial. JOURNAL OF MEDICAL ETHICS 2019; 45:662-667. [PMID: 31341013 DOI: 10.1136/medethics-2018-105138] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 06/12/2019] [Accepted: 07/01/2019] [Indexed: 06/10/2023]
Abstract
Ethics has been identified as a central reason for choosing the stepped wedge trial over other kinds of trial designs. The potential advantage of the stepped wedge design is that it provides all arms of the trial with the active intervention over the course of the study. Some groups receive it later than others, but the study intervention is not withheld from any group. This feature of the stepped wedge design seems particularly ethically advantageous in two instances: (1) when the study intervention appears especially likely to be effective and (2) when the consequences of not receiving the intervention may be dire. But despite an increase in the use of the stepped wedge design and appeals to its ethical superiority as the motivation for its selection, there has been limited attention to the stepped wedge trial in the ethics literature. In the following, I examine whether there are persuasive ethical reasons to prefer or to require a stepped wedge trial. I argue that while the stepped wedge design is ethically permissible, it is not morally superior to other kinds of trials. To this end, I examine the ethical justification for providing, withholding, and delaying interventions in research.
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Affiliation(s)
- Ariella Binik
- Department of Philosophy, McMaster University, Hamilton, Ontario, Canada
- Institute on Ethics & Policy for Innovation, McMaster University, Hamilton, Ontario, Canada
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31
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London AJ, Kimmelman J. Clinical Trial Portfolios: A Critical Oversight in Human Research Ethics, Drug Regulation, and Policy. Hastings Cent Rep 2019; 49:31-41. [DOI: 10.1002/hast.1034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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32
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Informed Consent Documents Used in Critical Care Trials Often Do Not Implement Recommendations. Crit Care Med 2019; 46:e111-e117. [PMID: 29088004 DOI: 10.1097/ccm.0000000000002815] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Informed consent documents are often poorly understood by research participants. In critical care, issues such as time pressure, patient capacity, and surrogate decision making complicate the consent process further. Recommendations exist for addressing critical care-specific consent issues; we examined how well existing practice implements these recommendations. DESIGN We conducted a systematic search of the literature for recommendations specific to critical care informed consent and rated existing informed consent documents on their implementation of 1) 18 of these critical care recommendations and 2) 36 previously developed general informed consent recommendations. Four hundred twelve registered critical care trials were identified and a request sent to the principal investigators for an example of the informed consent document associated with the trial. Each consent document was rated on both set of recommendations. SETTING We evaluated informed consent documents for trials conducted in English or French registered with clinicaltrials.gov. PATIENTS Not applicable. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS Independent coders rated implementation of each recommendation on a four-point scale. Of 412 requests, 137 informed consent documents were returned, for a response rate of 34.1%. Of these, 86 met inclusion criteria and were assessed. Overall agreement between raters was 90.6% (weighted κ = 0.79; 0.77-0.81). Implementation of the 18 critical care recommendations was highly variable, ranging between 2% and 96.5%. CONCLUSIONS Critical care studies often do not provide the information recommended for those providing consent for research. These clear recommendations provide testable hypotheses about how to improve the consent process for patients and family members considering trial participation in the critical care setting.
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Goldstein CE, Weijer C, Taljaard M, Al-Jaishi AA, Basile E, Brehaut J, Cook CL, Grimshaw JM, Lacson E, Lindsay C, Jardine M, Dember LM, Garg AX. Ethical Issues in Pragmatic Cluster-Randomized Trials in Dialysis Facilities. Am J Kidney Dis 2019; 74:659-666. [PMID: 31227227 DOI: 10.1053/j.ajkd.2019.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 04/13/2019] [Indexed: 11/11/2022]
Abstract
A pragmatic cluster-randomized trial (CRT) is a research design that may be used to efficiently test promising interventions that directly inform dialysis care. While the Ottawa Statement on the Ethical Design and Conduct of Cluster Randomized Trials provides general ethical guidance for CRTs, the dialysis setting raises additional considerations. In this article, we outline ethical issues raised by pragmatic CRTs in dialysis facilities. These issues may be divided into 7 key domains: justifying the use of cluster randomization, adopting randomly allocated individual-level interventions as a facility standard of care, conducting benefit-harm analyses, gatekeepers and their responsibilities, obtaining informed consent from research participants, patient notification, and including vulnerable participants. We describe existing guidelines relevant to each domain, illustrate how they were considered in the Time to Reduce Mortality in End-Stage Renal Disease (TiME) trial (a prototypical pragmatic hemodialysis CRT), and highlight remaining areas of uncertainty. The following is the first step in an interdisciplinary mixed-methods research project to guide the design and conduct of pragmatic CRTs in dialysis facilities. Subsequent work will expand on these concepts and when possible, argue for a preferred solution.
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Affiliation(s)
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, London
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute; School of Epidemiology and Public Health, University of Ottawa, Ottawa
| | - Ahmed A Al-Jaishi
- Institute for Clinical Evaluative Sciences, Toronto; Department of Health and Research Methods, Evidence, and Impact, McMaster University, Hamilton
| | | | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute; School of Epidemiology and Public Health, University of Ottawa, Ottawa
| | - Charles L Cook
- Patient partner with the SPOR Innovative Clinical Trials Initiative, London
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute; Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Eduardo Lacson
- Dialysis Clinic, Inc, Nashville, TN; Tufts University School of Medicine, Boston, MA
| | - Craig Lindsay
- Patient partner with the SPOR Innovative Clinical Trials Initiative, London
| | - Meg Jardine
- The George Institute for Global Health, University of New South Wales; Department of Renal Medicine, Concord Repatriation General Hospital and University of Sydney, Sydney, NSW, Australia
| | - Laura M Dember
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Amit X Garg
- Institute for Clinical Evaluative Sciences, Toronto; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton; Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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Mtande TK, Weijer C, Hosseinipour MC, Taljaard M, Matoga M, Goldstein CE, Nyambalo B, Rosenberg NE. Ethical issues raised by cluster randomised trials conducted in low-resource settings: identifying gaps in the Ottawa Statement through an analysis of the PURE Malawi trial. JOURNAL OF MEDICAL ETHICS 2019; 45:388-393. [PMID: 31189724 PMCID: PMC6613743 DOI: 10.1136/medethics-2019-105374] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/16/2019] [Accepted: 04/27/2019] [Indexed: 06/09/2023]
Abstract
The increasing use of cluster randomised trials in low-resource settings raises unique ethical issues. The Ottawa Statement on the Ethical Design and Conduct of Cluster Randomised Trials is the first international ethical guidance document specific to cluster trials, but it is unknown if it adequately addresses issues in low-resource settings. In this paper, we seek to identify any gaps in the Ottawa Statement relevant to cluster trials conducted in low-resource settings. Our method is (1) to analyse a prototypical cluster trial conducted in a low-resource setting (PURE Malawi trial) with the Ottawa Statement; (2) to identify ethical issues in the design or conduct of the trial not captured adequately and (3) to make recommendations for issues needing attention in forthcoming revisions to the Ottawa Statement Our analysis identified six ethical aspects of cluster randomised trials in low-resource settings that require further guidance. The forthcoming revision of the Ottawa Statement should provide additional guidance on these issues: (1) streamlining research ethics committee review for collaborating investigators who are affiliated with other institutions; (2) the classification of lay health workers who deliver study interventions as health providers or research participants; (3) the dilemma experienced by investigators when national standards seem to prohibit waivers of consent; (4) the timing of gatekeeper engagement, particularly when researchers face funding constraints; (5) providing ancillary care in health services or implementation trials when a routine care control arm is known to fall below national standards and (6) defining vulnerable participants needing protection in low-resource settings.
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Affiliation(s)
| | - Charles Weijer
- Rotman Institute of Philosophy, University of Western Ontario, London, Ontario, Canada
| | - Mina C Hosseinipour
- University of North Carolina Project, Lilongwe, Malawi
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Mitch Matoga
- University of North Carolina Project, Lilongwe, Malawi
| | - Cory E Goldstein
- Rotman Institute of Philosophy, Western University, London, Ontario, Canada
| | - Billy Nyambalo
- Research Department, Ministry of Health Malawi, Lilongwe, Malawi
| | - Nora E Rosenberg
- University of North Carolina Project, Lilongwe, Malawi
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Elameer M, Price C, Flynn D, Rodgers H. The impact of acute stroke service centralisation: a time series evaluation. Future Healthc J 2018; 5:181-187. [PMID: 31098563 PMCID: PMC6502604 DOI: 10.7861/futurehosp.5-3-181] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
We evaluated the impact of the centralisation of three acute stroke units into a single hyperacute stroke unit within a large urban and rural NHS trust in North East England in June 2015. We performed retrospective interrupted time series analyses of 4,305 stroke patients admitted between 1 April 2013 and 31 December 2017 utilising data recorded for the Sentinel Stroke National Audit Programme. Centralisation was -associated with reductions in total length of inpatient stay (-4.9 days [95% CI: -8.1 to -1.7]). Time from admission to thrombolysis shortened by 26.0 minutes (95% CI: -40.0 to -12.1), and time from admission to brain imaging for thrombolysed patients improved by 16.2 minutes (95% CI: -22.0 to -10.4). Time from stroke onset to hospital admission, mortality and dependency (as measured by median modified Rankin Scale) were unaffected by centralisation. This study provides further evidence to support the centralisation of acute stroke services in England.
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Affiliation(s)
- Mat Elameer
- Stroke Research Group, Newcastle University, Newcastle-upon-Tyne, UK
| | - Chris Price
- Stroke Research Group, Newcastle University, Newcastle-upon-Tyne, UK
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle-upon-Tyne, UK
| | - Helen Rodgers
- Stroke Research Group, Newcastle University, Newcastle-upon-Tyne, UK
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von Vopelius‐Feldt J, Brandling J, Benger J. Variations in stakeholders' priorities and views on randomisation and funding decisions in out-of-hospital cardiac arrest: An exploratory study. Health Sci Rep 2018; 1:e78. [PMID: 30623101 PMCID: PMC6266350 DOI: 10.1002/hsr2.78] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 06/08/2018] [Accepted: 06/18/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND AIMS Prehospital critical care for out-of-hospital cardiac arrest (OHCA) is a complex and largely unproven intervention. During research to examine this intervention, we noted significant differences in stakeholders' views about research, randomisation, and the funding of prehospital critical care for OHCA. We aimed to answer the following questions: What are stakeholders' priorities for prehospital research? What are stakeholders' views on randomisation of prehospital critical care? How do stakeholders consider allocation of resources in prehospital care? METHODS We undertook an explanatory qualitative framework analysis of interviews and focus group with 5 key stakeholder groups: patients and public, air ambulance charities, ambulance service commissioners, prehospital researchers, and prehospital critical care providers. RESULTS We undertook 3 focus group discussions with a total of 23 participants and 8 interviews with a total of 9 participants. Despite sharing a common appreciation of the concepts of scientific enquiry, fairness, and beneficence, the 5 relevant stakeholder groups displayed divergent views of research and funding strategies regarding the intervention of prehospital critical care for the condition of OHCA. The reasons for this divergence could largely be explained through the different personal experiences and situational contexts of each stakeholder group. Many aspects of the strategies suggested by the stakeholder groups only partially aligned with principles of traditional evidence-based medicine, but were held with strong conviction. DISCUSSION Analysis of the views of 5 stakeholder groups regarding research and the funding of prehospital critical care for OHCA revealed shared values but a variety of different strategies to achieve these. This knowledge can help researchers in similar fields in the planning and presentation of their research, to maximise impact on decision making.
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Affiliation(s)
- Johannes von Vopelius‐Feldt
- Academic Department of Emergency CareUniversity Hospitals Bristol NHS Foundation TrustBristolUK
- Emergency and Critical Care Research, Faculty of Health & Applied SciencesUniversity of the West of EnglandBristolUK
| | - Janet Brandling
- Emergency and Critical Care Research, Faculty of Health & Applied SciencesUniversity of the West of EnglandBristolUK
| | - Jonathan Benger
- Academic Department of Emergency CareUniversity Hospitals Bristol NHS Foundation TrustBristolUK
- Emergency and Critical Care Research, Faculty of Health & Applied SciencesUniversity of the West of EnglandBristolUK
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Baum A, Elize W, Jean-Louis F. Microfinance Institutions' Successful Delivery Of Micronutrient Powders: A Randomized Trial In Rural Haiti. Health Aff (Millwood) 2018; 36:1938-1946. [PMID: 29137512 DOI: 10.1377/hlthaff.2017.0281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Globally, two-thirds of child deaths could be prevented by increased provision of health interventions such as vaccines, micronutrient supplements, and water purification tablets. We report the results from a randomized controlled trial in Haiti during 2012 that tested whether microfinance institutions-which reach 200 million households worldwide-can effectively deliver health products. These institutions provide loans to underserved entrepreneurs, primarily poor women in rural areas. In the intervention group, micronutrient powders to improve the nutrition of young children were distributed at regularly occurring microfinance meetings by a trained borrower. In both the control and the intervention groups, nurses led seminars on nutrition and extended breastfeeding during microfinance meetings. At three-month follow-up, the mean difference in hemoglobin concentration between children in the intervention group and those in the control group was 0.28 grams per deciliter (g/dL)-with a subsample of younger children (under two years of age) showing greater relative improvement (0.46 g/dL)-and the odds ratio for children in the intervention group meeting the diagnostic criteria for anemia was 0.64. The results are similar to those of previous studies that evaluated micronutrient powder distribution through dedicated health institutions. Our findings suggest that microfinance institutions are a promising platform for the large-scale delivery of health products in low-income countries.
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Affiliation(s)
- Aaron Baum
- Aaron Baum ( ) is an assistant professor of health system design and global health at the Icahn School of Medicine at Mount Sinai and an economist at the Arnhold Institute for Global Health, both in New York City
| | - Wesly Elize
- Wesly Elize is a physician and health project officer at Fonkoze, in Port-au-Prince, Haiti
| | - Florence Jean-Louis
- Florence Jean-Louis is a physician and human development director at Fonkoze
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Nathan HL, Duhig K, Vousden N, Lawley E, Seed PT, Sandall J, Bellad MB, Brown AC, Chappell LC, Goudar SS, Gidiri MF, Shennan AH. Evaluation of a novel device for the management of high blood pressure and shock in pregnancy in low-resource settings: study protocol for a stepped-wedge cluster-randomised controlled trial (CRADLE-3 trial). Trials 2018; 19:206. [PMID: 29587875 PMCID: PMC5870727 DOI: 10.1186/s13063-018-2581-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 03/13/2018] [Indexed: 11/10/2022] Open
Abstract
Background Obstetric haemorrhage, sepsis and pregnancy hypertension account for more than 50% of maternal deaths worldwide. Early detection and effective management of these conditions relies on vital signs. The Microlife® CRADLE Vital Sign Alert (VSA) is an easy-to-use, accurate device that measures blood pressure and pulse. It incorporates a traffic-light early warning system that alerts all levels of healthcare provider to the need for escalation of care in women with obstetric haemorrhage, sepsis or pregnancy hypertension, thereby aiding early recognition of haemodynamic instability and preventing maternal mortality and morbidity. The aim of the trial was to determine whether implementation of the CRADLE intervention (the Microlife® CRADLE VSA device and CRADLE training package) into routine maternity care in place of existing equipment will reduce a composite outcome of maternal mortality and morbidity in low- and middle-income country populations. Methods The CRADLE-3 trial was a stepped-wedge cluster-randomised controlled trial of the CRADLE intervention compared to routine maternity care. Each cluster crossed from routine maternity care to the intervention at 2-monthly intervals over the course of 20 months (April 2016 to November 2017). All women identified as pregnant or within 6 weeks postpartum, presenting for maternity care in cluster catchment areas were eligible to participate. Primary outcome data (composite of maternal death, eclampsia and emergency hysterectomy per 10,000 deliveries) were collected at 10 clusters (Gokak, Belgaum, India; Harare, Zimbabwe; Ndola, Zambia; Lusaka, Zambia; Free Town, Sierra Leone; Mbale, Uganda; Kampala, Uganda; Cap Haitien, Haiti; South West, Malawi; Addis Ababa, Ethiopia). This trial was informed by the Medical Research Council guidance for complex interventions. A process evaluation was undertaken to evaluate implementation in each site and a cost-effectiveness evaluation will be undertaken. Discussion All aspects of this protocol have been evaluated in a feasibility study, with subsequent optimisation of the intervention. This trial will demonstrate the potential impact of the CRADLE intervention on reducing maternal mortality and morbidity in low-resource settings. It is anticipated that the relatively low cost of the intervention and ease of integration into existing health systems will be of significant interest to local, national and international health policy-makers. Trial registration ISCRTN41244132. Registered on 2 February 2016. Prospective protocol modifications have been recorded and were communicated to the Ethics Committees and Trials Committees. The adapted Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) Checklist and the SPIRIT Checklist are attached as Additional file 1. Electronic supplementary material The online version of this article (10.1186/s13063-018-2581-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hannah L Nathan
- Department of Women and Children's Health, King's College London, London, UK
| | - Kate Duhig
- Department of Women and Children's Health, King's College London, London, UK
| | - Nicola Vousden
- Department of Women and Children's Health, King's College London, London, UK
| | - Elodie Lawley
- Department of Women and Children's Health, King's College London, London, UK
| | - Paul T Seed
- Department of Women and Children's Health, King's College London, London, UK
| | - Jane Sandall
- Department of Women and Children's Health, King's College London, London, UK
| | - Mrutyunjaya B Bellad
- Department of Obstetrics and Gynaecology, KLE University's JN Medical College, Belgaum, Karnataka, India
| | - Adrian C Brown
- Maternity Worldwide, Community Base, 113 Queens Rd, Brighton, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London, London, UK
| | - Shivaprasad S Goudar
- Department of Obstetrics and Gynaecology, KLE University's JN Medical College, Belgaum, Karnataka, India
| | - Muchabayiwa F Gidiri
- Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
| | - Andrew H Shennan
- Department of Women and Children's Health, King's College London, London, UK.
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Taljaard M, Hemming K, Shah L, Giraudeau B, Grimshaw JM, Weijer C. Inadequacy of ethical conduct and reporting of stepped wedge cluster randomized trials: Results from a systematic review. Clin Trials 2017; 14:333-341. [PMID: 28393537 DOI: 10.1177/1740774517703057] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background/aims The use of the stepped wedge cluster randomized design is rapidly increasing. This design is commonly used to evaluate health policy and service delivery interventions. Stepped wedge cluster randomized trials have unique characteristics that complicate their ethical interpretation. The 2012 Ottawa Statement provides comprehensive guidance on the ethical design and conduct of cluster randomized trials, and the 2010 CONSORT extension for cluster randomized trials provides guidelines for reporting. Our aims were to assess the adequacy of the ethical conduct and reporting of stepped wedge trials to date, focusing on research ethics review and informed consent. Methods We conducted a systematic review of stepped wedge cluster randomized trials in health research published up to 2014 in English language journals. We extracted details of study intervention and data collection procedures, as well as reporting of research ethics review and informed consent. Two reviewers independently extracted data from each trial; discrepancies were resolved through discussion. We identified the presence of any research participants at the cluster level and the individual level. We assessed ethical conduct by tabulating reporting of research ethics review and informed consent against the presence of research participants. Results Of 32 identified stepped wedge trials, only 24 (75%) reported review by a research ethics committee, and only 16 (50%) reported informed consent from any research participants-yet, all trials included research participants at some level. In the subgroup of 20 trials with research participants at cluster level, only 4 (20%) reported informed consent from such participants; in 26 trials with individual-level research participants, only 15 (58%) reported their informed consent. Interventions (regardless of whether targeting cluster- or individual-level participants) were delivered at the group level in more than two-thirds of trials; nine trials (28%) had no identifiable data collected from any research participants. Overall, only three trials (9%) indicated that a waiver of consent had been granted by a research ethics committee. When considering the combined requirement of research ethics review and informed consent (or a waiver), only one in three studies were compliant. Conclusion The ethical conduct and reporting of key ethical protections in stepped wedge trials, namely, research ethics review and informed consent, are inadequate. We recommend that stepped wedge trials be classified as research and reviewed and approved by a research ethics committee. We also recommend that researchers appropriately identify research participants (which may include health professionals), seek informed consent or appeal to an ethics committee for a waiver of consent, and include explicit details of research ethics approval and informed consent in the trial report.
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Affiliation(s)
- Monica Taljaard
- 1 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,2 School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Karla Hemming
- 3 Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Lena Shah
- 4 Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Bruno Giraudeau
- 5 INSERM Unit U1246, SPHERE and Université de Tours, Université de Nantes, Tours, France.,6 INSERM CIC 1415, CHRU de Tours, Tours, France
| | - Jeremy M Grimshaw
- 1 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,8 Center for Practice-Changing Research, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Charles Weijer
- 9 Rotman Institute of Philosophy, Western University, London, ON, Canada.,10 Department of Medicine, Western University, London, ON, Canada.,11 Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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Pratt B, Paul A, Hyder AA, Ali J. Ethics of health policy and systems research: a scoping review of the literature. Health Policy Plan 2017; 32:890-910. [DOI: 10.1093/heapol/czx003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2017] [Indexed: 11/12/2022] Open
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Addissie A, Abay S, Feleke Y, Newport M, Farsides B, Davey G. Cluster randomized trial assessing the effects of rapid ethical assessment on informed consent comprehension in a low-resource setting. BMC Med Ethics 2016; 17:40. [PMID: 27406063 PMCID: PMC4943010 DOI: 10.1186/s12910-016-0127-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 06/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Maximizing comprehension is a major challenge for informed consent processes in low-literacy and resource-limited settings. Application of rapid qualitative assessments to improve the informed consent process is increasingly considered useful. This study assessed the effects of Rapid Ethical Assessment (REA) on comprehension, retention and quality of the informed consent process. METHODS A cluster randomized trial was conducted among participants of HPV sero-prevalence study in two districts of Northern Ethiopia, in 2013. A total of 300 study participants, 150 in the intervention and 150 in the control group, were included in the study. For the intervention group, the informed consent process was designed with further revisions based on REA findings. Informed consent comprehension levels and quality of the consent process were measured using the Modular Informed Consent Comprehension Assessment (MICCA) and Quality of Informed Consent (QuIC) process assessment tools, respectively. RESULT Study recruitment rates were 88.7 % and 80.7 % (p = 0.05), while study retention rates were 85.7 % and 70.3 % (p < 0.005) for the intervention and control groups respectively. Overall, the mean informed consent comprehension scores for the intervention and control groups were 73.1 % and 45.2 %, respectively, with a mean difference in comprehension score of 27.9 % (95 % CI 24.0 % - 33.4 %; p < 0.001,). Mean scores for quality of informed consent for the intervention and control groups were 89.1 % and 78.5 %, respectively, with a mean difference of 10.5 % (95 % CI 6.8 -14.2 %; p < 0.001). CONCLUSION Levels of informed consent comprehension, quality of the consent process, study recruitment and retention rates were significantly improved in the intervention group. We recommend REA as a potential modality to improve informed consent comprehension and quality of informed consent process in low resource settings.
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Affiliation(s)
- Adamu Addissie
- Brighton and Sussex Medical School, Brighton, UK. .,Addis Ababa University, Addis Ababa, Ethiopia.
| | - Serebe Abay
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | | | | | | | - Gail Davey
- Brighton and Sussex Medical School, Brighton, UK
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Abstract
BACKGROUND The cluster-randomized trial is the methodology of choice for evaluating interventions administered at the group level such as public health and healthcare quality improvement interventions. Because of unique features of this design, it can be difficult to apply standard research ethics guidelines to cluster-randomized trials. The Ottawa Statement on the Ethical Design and Conduct of Cluster-Randomized Trials provides researchers and research ethics committees with comprehensive guidance on the ethical design, conduct and review of cluster-randomized trials. The Ottawa Statement supplements current national and international research ethics guidelines with guidance that is specific to cluster-randomized trials. In a recently published commentary, three examples drawn from the ClinicalTrials.gov registry were used to illustrate challenges associated with the cluster-randomized trial design. The commentary argued that the Ottawa Statement fails to provide comprehensive ethical guidance. In this article, we illustrate the application of the Ottawa Statement to the three trials. We challenge the conclusions reached in the commentary by demonstrating that an ethical analysis requires complete information. We correct some misperceptions about the cluster-randomized trial design. METHODS We collected essential additional information by contacting the authors of trials and by referring to published trial articles. We used the Ottawa Statement to conduct an ethical analysis of each trial and to address a number of substantive concerns raised regarding the identification of study participants, informed consent and harm benefit analysis. RESULTS In the two cases in which we were able to obtain detailed study information, we were able to complete the ethical analysis prescribed by the Ottawa Statement. CONCLUSION The Ottawa Statement does provide a useful framework for the ethical design, review and conduct of cluster-randomized trials.
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Affiliation(s)
- Andrew D McRae
- Department of Emergency Medicine, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Monica Taljaard
- Rotman Institute of Philosophy, Western University, London, ON, Canada Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, London, ON, Canada Department of Medicine, University of Western Ontario, London, ON, Canada Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada
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Rebers S, Aaronson NK, van Leeuwen FE, Schmidt MK. Exceptions to the rule of informed consent for research with an intervention. BMC Med Ethics 2016; 17:9. [PMID: 26852412 PMCID: PMC4744424 DOI: 10.1186/s12910-016-0092-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 01/29/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In specific situations it may be necessary to make an exception to the general rule of informed consent for scientific research with an intervention. Earlier reviews only described subsets of arguments for exceptions to waive consent. METHODS Here, we provide a more extensive literature review of possible exceptions to the rule of informed consent and the accompanying arguments based on literature from 1997 onwards, using both Pubmed and PsycINFO in our search strategy. RESULTS We identified three main categories of arguments for the acceptability of a consent waiver: data validity and quality, major practical problems, and distress or confusion of participants. Approval by a medical ethical review board always needs to be obtained. Further, we provide examples of specific conditions under which consent waiving might be allowed, such as additional privacy protection measures. CONCLUSIONS The reasons legitimized by the authors of the papers in this overview can be used by researchers to form their own opinion about requesting an exception to the rule of informed consent for their own study. Importantly, rules and guidelines applicable in their country, institute and research field should be followed. Moreover, researchers should also take the conditions under which they feel an exception is legitimized under consideration. After discussions with relevant stakeholders, a formal request should be sent to an IRB.
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Affiliation(s)
- Susanne Rebers
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Neil K Aaronson
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Flora E van Leeuwen
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Marjanka K Schmidt
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
- Division of Molecular Pathology, The Netherlands Cancer Institute, Postbus 90203, 1006 BE, Amsterdam, The Netherlands.
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Esserman D, Allore HG, Travison TG. The Method of Randomization for Cluster-Randomized Trials: Challenges of Including Patients with Multiple Chronic Conditions. ACTA ACUST UNITED AC 2016; 5:2-7. [PMID: 27478520 PMCID: PMC4963011 DOI: 10.6000/1929-6029.2016.05.01.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Cluster-randomized clinical trials (CRT) are trials in which the unit of randomization is not a participant but a group (e.g. healthcare systems or community centers). They are suitable when the intervention applies naturally to the cluster (e.g. healthcare policy); when lack of independence among participants may occur (e.g. nursing home hygiene); or when it is most ethical to apply an intervention to all within a group (e.g. school-level immunization). Because participants in the same cluster receive the same intervention, CRT may approximate clinical practice, and may produce generalizable findings. However, when not properly designed or interpreted, CRT may induce biased results. CRT designs have features that add complexity to statistical estimation and inference. Chief among these is the cluster-level correlation in response measurements induced by the randomization. A critical consideration is the experimental unit of inference; often it is desirable to consider intervention effects at the level of the individual rather than the cluster. Finally, given that the number of clusters available may be limited, simple forms of randomization may not achieve balance between intervention and control arms at either the cluster- or participant-level. In non-clustered clinical trials, balance of key factors may be easier to achieve because the sample can be homogenous by exclusion of participants with multiple chronic conditions (MCC). CRTs, which are often pragmatic, may eschew such restrictions. Failure to account for imbalance may induce bias and reducing validity. This article focuses on the complexities of randomization in the design of CRTs, such as the inclusion of patients with MCC, and imbalances in covariate factors across clusters.
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Affiliation(s)
- Denise Esserman
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Heather G Allore
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Thomas G Travison
- Department of Medicine, Harvard Medical School, Cambridge, Massachusetts, USA; Hebrew SeniorLife Institute for Aging Research, Roslindale, Massachusetts, USA
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Tume LN, Preston J, Blackwood B. Parents' and young people's involvement in designing a trial of ventilator weaning. Nurs Crit Care 2015; 21:e10-8. [PMID: 26486094 DOI: 10.1111/nicc.12221] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 08/04/2015] [Accepted: 09/05/2015] [Indexed: 01/05/2023]
Abstract
Consulting with users is considered best practice and is highly recommended in designing new trials. As part of our feasibility work, we undertook a consultation exercise with parents, ex-patients and young people prior to designing a trial of protocol-based ventilator weaning. Our aims were to (1) ascertain views on the relevance and importance of the trial; (2) determine the important parent/patient outcome measures; and (3) ascertain views on informed consent in a cluster randomized controlled trial. We conducted audio-recorded face-to-face, telephone and focus group interviews with parents and young people. Data were content analysed to generate information to address our specific consultation objectives. The setting was the north-western region of England. A total of 16 participants were interviewed: 2 parents of paediatric intensive care unit (PICU) survivors; 1 PICU survivor; and 13 young people from the former Medicines for Children Research Network. The trial objectives were deemed important and relevant, and participants considered the most important outcome measure to be the length of time on ventilation. Parents and young people did not consider written informed consent to be a necessary requirement in the context of this trial, rather awareness of unit participation in the trial was important with the opportunity of opting out of data collection. This consultation provided useful, pragmatic insights to inform trial design. We encountered significant challenges in recruiting parents and young people for this consultation exercise, and novel recruitment methods need to be considered for future work in this field. Patient and public involvement is essential to ensure that future trials answer parent-relevant questions and have meaningful outcome measures, as well as involving parents and young people in the general development of health care services.
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Affiliation(s)
- Lyvonne N Tume
- PICU and Children's Nursing Research Unit, Alder Hey Children's NHS FT, Liverpool, UK.,School of Health, University of Central Lancashire, Preston, UK
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Taljaard M, Chaudhry SH, Brehaut JC, Weijer C, Grimshaw JM. Mail merge can be used to create personalized questionnaires in complex surveys. BMC Res Notes 2015; 8:574. [PMID: 26475715 PMCID: PMC4608177 DOI: 10.1186/s13104-015-1570-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 10/07/2015] [Indexed: 11/12/2022] Open
Abstract
Background Low response rates and inadequate question comprehension threaten the validity of survey results. We describe a simple procedure to implement personalized—as opposed to generically worded—questionnaires in the context of a complex web-based survey of corresponding authors of a random sample of 300 published cluster randomized trials. The purpose of the survey was to gather more detailed information about informed consent procedures used in the trial, over and above basic information provided in the trial report. We describe our approach—which allowed extensive personalization without the need for specialized computer technology—and discuss its potential application in similar settings. Results The mail merge feature of standard word processing software was used to generate unique, personalized questionnaires for each author by incorporating specific information from the article, including naming the randomization unit (e.g., family practice, school, worksite), and identifying specific individuals who may have been considered research participants at the cluster level (family doctors, teachers, employers) and individual level (patients, students, employees) in questions regarding informed consent procedures in the trial. The response rate was relatively high (64 %, 182/285) and did not vary significantly by author, publication, or study characteristics. The refusal rate was low (7 %). Conclusion While controlled studies are required to examine the specific effects of our approach on comprehension, quality of responses, and response rates, we showed how mail merge can be used as a simple but useful tool to add personalized fields to complex survey questionnaires, or to request additional information required from study authors. One potential application is in eliciting specific information about published articles from study authors when conducting systematic reviews and meta-analyses.
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Affiliation(s)
- Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa Hospital, 1053 Carling Avenue, Civic Campus, Admin Services Building, C409, ASB 2-004, Civic Box 693, Ottawa, ON, K1Y 4E9, Canada. .,Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada. .,Rotman Institute of Philosophy, Western University, London, ON, Canada.
| | - Shazia Hira Chaudhry
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Jamie C Brehaut
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Road, Box 711, Ottawa, ON, K1H 8L6, Canada.
| | - Charles Weijer
- Rotman Institute 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.
| | - Jeremy M Grimshaw
- Rotman Institute of Philosophy, Western University, London, ON, Canada. .,Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, General Campus, 501 Smyth Road, Box 711, Ottawa, ON, K1H 8L6, Canada.
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Welch MJ, Lally R, Miller JE, Pittman S, Brodsky L, Caplan AL, Uhlenbrauck G, Louzao DM, Fischer JH, Wilfond B. The ethics and regulatory landscape of including vulnerable populations in pragmatic clinical trials. Clin Trials 2015. [PMID: 26374681 DOI: 10.1177/174074515597701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Policies have been developed to protect vulnerable populations in clinical research, including the US federal research regulations (45 Code of Federal Regulations 46 Subparts B, C, and D). These policies generally recognize vulnerable populations to include pregnant women, fetuses, neonates, children, prisoners, persons with physical handicaps or mental disabilities, and disadvantaged persons. The aim has been to protect these populations from harm, often by creating regulatory and ethical checks that may limit their participation in many clinical trials. The recent increase in pragmatic clinical trials raises at least two questions about this approach. First, is exclusion itself a harm to vulnerable populations, as these groups may be denied access to understanding how health interventions work for them in clinical settings? Second, are groups considered vulnerable in traditional clinical trials also vulnerable in pragmatic clinical trials? We argue first that excluding vulnerable subjects from participation in pragmatic clinical trials can be harmful by preventing acquisition of data to meaningfully inform clinical decision-making in the future. Second, we argue that protections for vulnerable subjects in traditional clinical trial settings may not be translatable, feasible, or even ethical to apply in pragmatic clinical trials. We conclude by offering specific recommendations for appropriately protecting vulnerable research subjects in pragmatic clinical trials, focusing on pregnant women, fetuses, neonates, children, prisoners, persons with physical handicaps or mental disabilities, and disadvantaged persons.
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Affiliation(s)
- Mary Jane Welch
- Human Subjects' Protection, College of Nursing, Rush University Medical Center, Chicago, IL, USA
| | - Rachel Lally
- Columbia University Medical Center, New York, NY, USA
| | - Jennifer E Miller
- Kenan Institute for Ethics, Duke University, Durham, NC, USA Edmond J. Safra Center for Ethics, Harvard University, Cambridge, MA, USA Division of Medical Ethics, NYU Langone Medical Center, New York, NY, USA
| | - Stephanie Pittman
- Human Subjects' Protection, Rush University Medical Center, Chicago, IL, USA
| | - Lynda Brodsky
- Cook County Health & Hospitals System, Chicago, IL, USA
| | - Arthur L Caplan
- Division of Medical Ethics, NYU Langone Medical Center, New York, NY, USA
| | - Gina Uhlenbrauck
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Darcy M Louzao
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Benjamin Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, WA, USA Division of Bioethics, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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Abstract
To successfully implement a pragmatic clinical trial, investigators need access to numerous resources, including financial support, institutional infrastructure (e.g. clinics, facilities, staff), eligible patients, and patient data. Gatekeepers are people or entities who have the ability to allow or deny access to the resources required to support the conduct of clinical research. Based on this definition, gatekeepers relevant to the US clinical research enterprise include research sponsors, regulatory agencies, payers, health system and other organizational leadership, research team leadership, human research protections programs, advocacy and community groups, and clinicians. This article provides a framework to help guide gatekeepers' decision-making related to the use of resources for pragmatic clinical trials. Relevant ethical considerations for gatekeepers include (1) concern for the interests of individuals, groups, and communities affected by the gatekeepers' decisions, including protection from harm and maximization of benefits; (2) advancement of organizational mission and values; and (3) stewardship of financial, human, and other organizational resources. Separate from these ethical considerations, gatekeepers' actions will be guided by relevant federal, state, and local regulations. This framework also suggests that to further enhance the legitimacy of their decision-making, gatekeepers should adopt transparent processes that engage relevant stakeholders when feasible and appropriate. We apply this framework to the set of gatekeepers responsible for making decisions about resources necessary for pragmatic clinical trials in the United States, describing the relevance of the criteria in different situations and pointing out where conflicts among the criteria and relevant regulations may affect decision-making. Recognition of the complex set of considerations that should inform decision-making will guide gatekeepers in making justifiable choices regarding the use of limited and valuable resources.
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Affiliation(s)
| | - Jennifer E Miller
- Kenan Institute for Ethics, Duke University, Durham, NC, USA Edmond J. Safra Center for Ethics, Harvard University, Cambridge, MA, USA
| | - Kelly M Dunham
- Patient-Centered Outcomes Research Institute, Washington, DC, USA
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Welch MJ, Lally R, Miller JE, Pittman S, Brodsky L, Caplan AL, Uhlenbrauck G, Louzao DM, Fischer JH, Wilfond B. The ethics and regulatory landscape of including vulnerable populations in pragmatic clinical trials. Clin Trials 2015; 12:503-10. [PMID: 26374681 DOI: 10.1177/1740774515597701] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Policies have been developed to protect vulnerable populations in clinical research, including the US federal research regulations (45 Code of Federal Regulations 46 Subparts B, C, and D). These policies generally recognize vulnerable populations to include pregnant women, fetuses, neonates, children, prisoners, persons with physical handicaps or mental disabilities, and disadvantaged persons. The aim has been to protect these populations from harm, often by creating regulatory and ethical checks that may limit their participation in many clinical trials. The recent increase in pragmatic clinical trials raises at least two questions about this approach. First, is exclusion itself a harm to vulnerable populations, as these groups may be denied access to understanding how health interventions work for them in clinical settings? Second, are groups considered vulnerable in traditional clinical trials also vulnerable in pragmatic clinical trials? We argue first that excluding vulnerable subjects from participation in pragmatic clinical trials can be harmful by preventing acquisition of data to meaningfully inform clinical decision-making in the future. Second, we argue that protections for vulnerable subjects in traditional clinical trial settings may not be translatable, feasible, or even ethical to apply in pragmatic clinical trials. We conclude by offering specific recommendations for appropriately protecting vulnerable research subjects in pragmatic clinical trials, focusing on pregnant women, fetuses, neonates, children, prisoners, persons with physical handicaps or mental disabilities, and disadvantaged persons.
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Affiliation(s)
- Mary Jane Welch
- Human Subjects' Protection, College of Nursing, Rush University Medical Center, Chicago, IL, USA
| | - Rachel Lally
- Columbia University Medical Center, New York, NY, USA
| | - Jennifer E Miller
- Kenan Institute for Ethics, Duke University, Durham, NC, USA Edmond J. Safra Center for Ethics, Harvard University, Cambridge, MA, USA Division of Medical Ethics, NYU Langone Medical Center, New York, NY, USA
| | - Stephanie Pittman
- Human Subjects' Protection, Rush University Medical Center, Chicago, IL, USA
| | - Lynda Brodsky
- Cook County Health & Hospitals System, Chicago, IL, USA
| | - Arthur L Caplan
- Division of Medical Ethics, NYU Langone Medical Center, New York, NY, USA
| | - Gina Uhlenbrauck
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Darcy M Louzao
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Benjamin Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, WA, USA Division of Bioethics, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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Adams P, Prakobtham S, Limphattharacharoen C, Vutikes P, Khusmith S, Pengsaa K, Wilairatana P, Kaewkungwal J. Ethical considerations in malaria research proposal review: empirical evidence from 114 proposals submitted to an Ethics Committee in Thailand. Malar J 2015; 14:342. [PMID: 26370243 PMCID: PMC4570222 DOI: 10.1186/s12936-015-0854-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 08/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria research is typically conducted in developing countries in areas of endemic disease. This raises specific ethical issues, including those related to local cultural concepts of health and disease, the educational background of study subjects, and principles of justice at the community and country level. Research Ethics Committees (RECs) are responsible for regulating the ethical conduct of research, but questions have been raised whether RECs facilitate or impede research, and about the quality of REC review itself. This study examines the review process for malaria research proposals submitted to the Ethics Committee of the Faculty of Tropical Medicine at Mahidol University, Thailand. METHODS Proposals for all studies submitted for review from January 2010 to December 2014 were included. Individual REC members' reviewing forms were evaluated. Ethical issues (e.g., scientific merit, risk-benefit, sample size, or informed-consent) raised in the forms were counted and analysed according to characteristics, including study classification/design, use of specimens, study site, and study population. RESULTS All 114 proposals submitted during the study period were analysed, comprising biomedical studies (17 %), drug trials (13 %), laboratory studies (24 %) and epidemiological studies (46 %). They included multi-site (13 %) and international studies (4 %), and those involving minority populations (28 %), children (17 %) and pregnant women (7 %). Drug trials had the highest proportion of questions raised for most ethical issues, while issues concerning privacy and confidentiality tended to be highest for laboratory and epidemiology studies. Clarifications on ethical issues were requested by the ethics committee more for proposals involving new specimen collection. Studies involving stored data and specimens tended to attract more issues around privacy and confidentiality. Proposals involving minority populations were more likely to raise issues than those that did not. Those involving vulnerable populations were more likely to attract concerns related to study rationale and design. CONCLUSIONS This study stratified ethical issues raised in a broad spectrum of research proposals. The Faculty of Tropical Medicine at Mahidol University is a significant contributor to global malaria research output. The findings shed light on the ethical review process that may be useful for stakeholders, including researchers, RECs and sponsors, conducting malaria research in other endemic settings.
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Affiliation(s)
- Pornpimon Adams
- Office of Research Services, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Sukanya Prakobtham
- Office of Research Services, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | | | - Pitchapa Vutikes
- Office of Research Services, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Srisin Khusmith
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Krisana Pengsaa
- Department of Tropical Pediatrics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Polrat Wilairatana
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Jaranit Kaewkungwal
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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