Methodological approaches for conducting follow-up research with clinical trial participants: a scoping review and expert interviews

Decisions, Decisions: Observations of Resource Allocation Under Consumer-Directed Care

Introduction: Resource trade-offs are a universal feature of decision-making in healthcare. Public funding for home care is an example of a complex resource allocation decision, requiring balance between the needs of the individual and the capacity of the welfare system to meet those needs across the population. Under consumer-directed care policies, responsibility for resource allocation decisions rests with the care recipient, but there is no existing measure of allocative efficiency resulting from these consumer-led decisions. Our research considers resource allocation decisions by home care package recipients under consumer-directed care and evaluates the consistency of consumer-directed resource allocation with medically identified recommendations. Method: Retrospective cohort analysis of twenty home care package resource allocations made by home care package recipients in South-East Queensland, compared to associated medically identified needs and discussions with a potential service provider. Findings: Resource allocation decisions in the Australian home care setting are complex, multi-faceted, and made in highly uncertain environments. There are significant differences between services and equipment recommendations made by assessment teams, service providers, and home care recipient choices. Discussion: Awareness of the decision-making process and resulting decisions provides a foundation for future research to simplify decision-making for home care package recipients without sacrificing autonomy, leading to improved resource allocation efficiency and home care program outcomes. Conclusion: Consumer-directed care is a globally popular policy position to allocate public funds related to health care needs, despite uncertainty around the impact of this policy on program outcomes. Our analysis suggests further understanding of factors influencing resource allocation decisions is needed to define appropriate supports for effective decision-making in home care resource allocation, and further research effort is required to determine efficient resource allocation to inform policy changes, irrespective of the decision-maker.

Decentralized clinical trials are better for the participants and for the planet: the case study of a double-blind randomized controlled trial in Singapore (PROMOTE study)

Introduction

Novel technologies have enabled the decentralization of many aspects of clinical trials, but little research has been done on the impact of these changes on the participant experience, trial operations, or the environment.

Methods

A fully decentralized clinical trial conducted in Singapore is used as a case study to evaluate the operational outcomes, environmental impact (via life cycle assessment), and participants experience (qualitative interviews) of the decentralized model compared to a traditional study with in-person visits.

Results

The decentralized study achieved high participant retention rates (97%) and high completion rates for clinical data, even for biological samples. Participants found the decentralized model to be convenient and safe, especially during the pandemic. Moreover, the decentralized model was found to be more environmentally friendly and less detrimental to human health compared to traditional face-to-face clinical trials, primarily by reducing participants' use of cars for site visits.

Discussion

While this study focused on the environmental impact, it is important to consider other factors such as participant safety, convenience, and data quality when evaluating the suitability of a decentralized clinical trial approach. Careful planning of data flow, database structure, and data protection measures is essential. This study contributes to improving the environmental footprint of clinical trials. Environmental sustainability should be among the factors that are evaluated when selecting trial models. Decentralized and hybrid clinical trials offer efficiency, effectiveness, and environmental benefits. Further research and adoption of these approaches are encouraged.

Self-reported chronic therapy use after 24-weeks of follow-up by participants who completed the simplify randomized, controlled trial

BACKGROUND

Highly effective CFTR modulator therapy (HEMT) has improved the health of many people with cystic fibrosis (pwCF), offering opportunities to discontinue burdensome therapies. SIMPLIFY included randomized, controlled trials that confirmed non-inferiority of discontinuing versus continuing dornase alfa (DA) or hypertonic saline (HS) for 6 weeks in pwCF on HEMT. In this study of post-trial treatment use by SIMPLIFY participants, we hypothesized that randomization to discontinue DA or HS during the trial would be associated with a higher likelihood of non-use of each medication during follow-up.

METHODS

We electronically surveyed SIMPLIFY participants every 4 weeks for 24 weeks after trial completion but before the main trial results were publicly disclosed. We asked them how often they used medications during the previous week. We estimated covariate-adjusted odds ratios (ORs) of DA or HS non-use by logistic regression with generalized estimating equations.

RESULTS

After exclusions mostly due to lack of any surveys, 472 participants were included in the analysis population, 181 from the HS trial and 291 from the DA trial. Approximately half of the analysis population completed all six surveys. At every month of follow-up in both trials, the percentage of individuals reporting non-use of DA or HS during the previous week was greater among those randomized to discontinue therapy. Among participants with responses at 24 weeks, 30/122 (24.6 %) in the HS trial and 79/222 (35.6 %) in the DA trial reported non-use of the respective study medication. After adjusting for covariates, participants randomized to discontinue DA were 8.7-times (95 % CI: 4.3-17.7) more likely to not use DA during follow-up than those randomized to continue DA, and participants randomized to discontinue HS were 5.2-times (95 % CI: 2.1-12.8) more likely to not use HS during follow-up compared to those randomized to continue.

CONCLUSIONS

In healthy pwCF on ETI, randomization to discontinue DA or HS during SIMPLIFY was associated with greater odds of not using each medication after the trial compared to randomization to continue. These findings suggest that participation in a treatment discontinuation trial can influence participants' post-trial treatment decisions. This possibility may be relevant during discussions about research participation and clinical care.

Participant Experience of Taking Part in Periodontal Experimental Studies

Objective: Despite the plethora of published periodontal interventional and experimental studies, there are no reports evaluating the experience of the participants as a research subject or their willingness for repeat participation in a similar study. This study aimed to determine the participants' experience and willingness to participate again in periodontal experimental studies and to explore factors that affect the participants' research experience. Materials and Methods: Questionnaires from four completed experimental wound healing studies with 76 total participants were extracted and analyzed. The participants answered the same specific questions at their last study visit. The questions asked were "overall experience in the study" and "willingness to participate in the study again," with each question providing five levels/possible answers. Questionnaires also provided an opportunity for participants to offer open-ended comments about their participation. Frequency distribution and logistic regression analyses were performed to evaluate the association between the participant's responses and study characteristics. Results: All 76 participants answered the specific questions. Overall, 88.2% of participants had a positive experience from their research participation, and 65.8% of them would participate again in such a study. Of the 76 participants, 50 were in studies that included multiple (≥2) experimental wounds, while 26 received only a single experimental wound. Participation experience was negatively associated with the number of wounds received (p < 0.001), while willingness to participate again was positively associated with participation experience (p < 0.001). Conclusions: Within the present study limitations, volunteers participating in periodontal experimental studies have an overall positive experience and express willingness for repeat participation.

Patients' experiences of clinical trial participation involving a product remotely assessing study drug adherence

Background

The participation of patients in clinical trials is crucial for the development of healthcare. There are several challenges in the recruitment of trial participants with acute medical conditions. The registry-based randomized DAPA-MI clinical trial recruited patients during hospitalization for myocardial infarction and provided study drugs in bottles with smart caps that used wireless technology to transmit monitoring data. This interview study aimed to investigate patients' experience of participation in a clinical trial and their attitude to the new bottle cap technology.

Methods

A subset of patients participating in the DAPA-MI trial were recruited from four hospitals in Sweden. Semi-structured interviews were conducted and analysed using manifest content analysis.

Results

Video interviews were performed including 21 patients (four women and 17 men). The median age was 59 years (range 44-80). Four categories of patients' experiences were identified. A willingness to contribute consisted of patients' positive attitudes to participation and to be a part of development and research. The perception of information emphasized the value of the oral information as well as the importance of time for reflection. Be in a vulnerable condition highlighted the impaired ability to perceive and remember in the acute medical condition. Adaptation to a new technology described the overall positive experiences of the smart bottle cap to evaluate adherence.

Conclusions

Patients' experiences of trial participation were in general positive but some challenges in the acute setting of a myocardial infarction were revealed. The smart bottle cap was well accepted, despite some handling difficulties.

"There was No Opportunity to Express Good or Bad": Perspectives From Patient Focus Groups on Patient Experience in Clinical Trials

To understand how patients perceive their experiences leading up to, during, and after a clinical trial, and the relationship these experiences had with future willingness to participate, we conducted 3 focus groups with patients who had prior clinical trial involvement (n  =  25). Discussion topics included clinical trial discovery, enrollment, communication, trust, patient-centricity, and future enrollment. Patient focus groups revealed a variety of motivations for enrolling in clinical trials (eg, altruism, efficacious treatment, curiosity, desperation, etc.). Patients learned about clinical trials through trusted sources (eg, primary care physicians, patient advocacy groups) and social media. Access and uncertainty about clinical trials were barriers to enrollment. Patient-centric communication and attention given to disease states and symptom severity were valued and made patients feel genuinely cared about. Post-trial follow up and being informed of trial results were inconsistently reported by patients. Critically, patients described frustration with an overall lack of patient experience measurement. Patients identified a need to measure experiences before, during, and after clinical trials and emphasized that doing so would facilitate patient trust and overall experience.

Empowering the Participant Voice (EPV): Design and implementation of collaborative infrastructure to collect research participant experience feedback at scale

Empowering the Participant Voice (EPV) is an NCATS-funded six-CTSA collaboration to develop, demonstrate, and disseminate a low-cost infrastructure for collecting timely feedback from research participants, fostering trust, and providing data for improving clinical translational research. EPV leverages the validated Research Participant Perception Survey (RPPS) and the popular REDCap electronic data-capture platform. This report describes the development of infrastructure designed to overcome identified institutional barriers to routinely collecting participant feedback using RPPS and demonstration use cases. Sites engaged local stakeholders iteratively, incorporating feedback about anticipated value and potential concerns into project design. The team defined common standards and operations, developed software, and produced a detailed planning and implementation Guide. By May 2023, 2,575 participants diverse in age, race, ethnicity, and sex had responded to approximately 13,850 survey invitations (18.6%); 29% of responses included free-text comments. EPV infrastructure enabled sites to routinely access local and multi-site research participant experience data on an interactive analytics dashboard. The EPV learning collaborative continues to test initiatives to improve survey reach and optimize infrastructure and process. Broad uptake of EPV will expand the evidence base, enable hypothesis generation, and drive research-on-research locally and nationally to enhance the clinical research enterprise.

Participant Experience with Protocol Research Kidney Biopsies in the Kidney Precision Medicine Project

BACKGROUND

Kidney biopsies are procedures commonly performed in clinical nephrology and are increasingly used in research. In this study, we aimed to evaluate the experiences of participants who underwent research kidney biopsies in the Kidney Precision Medicine Project (KPMP).

METHODS

KPMP research participants with AKI or CKD were enrolled at nine recruitment sites in the United States between September 2019 and January 2023. At 28 days postbiopsy, participants were invited to complete a survey to share their experiences, including motivation to participate in research, comprehension of informed consent, pain and anxiety during and after the biopsy procedure, overall satisfaction with KPMP participation, and effect of the study on their lives. The survey was developed in collaboration with the KPMP Community Engagement Committee and the Institute of Translational Health Sciences at the University of Washington.

RESULTS

One hundred and eleven participants completed the survey, 23 enrolled for AKI and 88 for CKD. The median age was 61 (interquartile range [IQR], 48-67) years, 43% were women, 28% were Black, and 18% were of Hispanic ethnicity. Survey respondents most commonly joined KPMP to help future patients (59%). The consent form was understood by 99%, and 97% recognized their important role in this study. Pain during the biopsy was reported by 50%, at a median level of 1 (IQR, 0-3) on a 0-10 scale. Anxiety during the biopsy was described by 64% at a median level of 3 (IQR, 1-5) on a 0-10 scale. More than half conveyed that KPMP participation had an effect on their diet, physical activity, and how they think about kidney disease.

CONCLUSIONS

KPMP survey respondents were most commonly motivated to participate in research protocol kidney biopsies by altruism, with excellent understanding of the informed consent process.

PODCAST

This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_11_20_CJN0000000000000334.mp3This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_11_20_Spanish_CJN00000000.mp3.

Commentary: an industry perspective on the importance of incorporating participant voice before, during, and after clinical trials

It is increasingly recognized that involving patients and the public in the design of clinical trials can lead to better recruitment, retention, and satisfaction. A recent scoping review determined that between 1985 and 2018, just 23 articles meeting quality criteria obtained feedback from clinical trial participants after a trial had been completed. In a timespan that presumably included thousands of trials across hundreds of indications, the paucity of the literature seems surprising, if not outright disappointing. By contrast, practitioners in the life sciences industry are increasingly incorporating patient research into their trial design process before, during, and after trial completion. Examples of approaches used include recruitment of “look alike” participant samples through online communities, surveys, and the use of smartphone apps to directly record participants’ spoken reactions to trial materials like recruitment materials, site visit schedules, or informed consent materials. However, commercial organizations tend not to publish their findings, leading to a potential two-tier experience for trial participants depending on whether the trial they participate in will be industry-funded or government-funded. This seems problematic on a number of levels. Increasing regulatory, funder, and publisher interest in improving the inclusivity of clinical trial participants may act as a timely lever to spur patient-centered coproduction of trials. Until continuous feedback processes are the mandated, funded, and published norm, participating in a clinical trial will be more arduous than it needs to be.