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Krutsinger DC, Maloney SI, Courtright KR, Bartels K. Barriers and Facilitators of Surrogates Providing Consent for Critically Ill Patients in Clinical Trials: A Qualitative Study. Chest 2024; 166:304-310. [PMID: 38387647 DOI: 10.1016/j.chest.2024.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Enrollment into critical care clinical trials is often hampered by the need to rely on surrogate decision-makers. To identify potential interventions facilitating enrollment into critical care clinical trials, a better understanding of surrogate decision-making for critical care clinical trial enrollment is needed. RESEARCH QUESTION What are the barriers and facilitators of critical care trial enrollment? What are surrogate decision-makers' perspectives on proposed interventions to facilitate trial enrollment? STUDY DESIGN AND METHODS We conducted semistructured interviews with 20 surrogate decision-makers of critically ill patients receiving mechanical ventilation. The interviews were recorded and transcribed verbatim, and analyzed for themes using an inductive approach. RESULTS Thematic analysis confirmed previous research showing that trust in the system, assessing the risks and benefits of trial participation, the desire to help others, and building medical knowledge as important motivating factors for trial enrollment. Two previously undescribed concerns among surrogate decision-makers of critically ill patients were identified, including the potential to interfere with clinical treatment decisions and negative sentiment about placebos. Surrogates viewed public recognition and charitable donations for participation as favorable potential interventions to encourage trial enrollment. However, participants viewed direct financial incentives and prioritizing research participants during medical rounds negatively. INTERPRETATION This study confirms and extends previous findings that health system trust, study risks and benefits, altruism, knowledge generation, interference with clinical care, and placebos are key concerns and barriers for surrogate decision-makers to enroll patients in critical care trials. Future studies are needed to evaluate if charitable giving on the patient's behalf and public recognition are effective strategies to promote enrollment into critical care trials.
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Affiliation(s)
- Dustin C Krutsinger
- Divisions of Pulmonary, Critical Care, and Sleep Medicine, University of Nebraska Medical Center, Omaha, NE; Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE.
| | - Shannon I Maloney
- Maurer College of Public Health, University of Nebraska Medical Center, Omaha, NE
| | - Katherine R Courtright
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Karsten Bartels
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
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Wick KD, Aggarwal NR, Curley MAQ, Fowler AA, Jaber S, Kostrubiec M, Lassau N, Laterre PF, Lebreton G, Levitt JE, Mebazaa A, Rubin E, Sinha P, Ware LB, Matthay MA. Opportunities for improved clinical trial designs in acute respiratory distress syndrome. THE LANCET. RESPIRATORY MEDICINE 2022; 10:916-924. [PMID: 36057279 DOI: 10.1016/s2213-2600(22)00294-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/02/2022] [Accepted: 07/19/2022] [Indexed: 02/08/2023]
Abstract
The acute respiratory distress syndrome (ARDS) is a common critical illness syndrome with high morbidity and mortality. There are no proven pharmacological therapies for ARDS. The current definition of ARDS is based on shared clinical characteristics but does not capture the heterogeneity in clinical risk factors, imaging characteristics, physiology, timing of onset and trajectory, and biology of the syndrome. There is increasing interest within the ARDS clinical trialist community to design clinical trials that reduce heterogeneity in the trial population. This effort must be balanced with ongoing work to craft an inclusive, global definition of ARDS, with important implications for trial design. Ultimately, the two aims-to design trials that are applicable to the diverse global ARDS population while also advancing opportunities to identify targetable traits-should coexist. In this Personal View, we recommend two primary strategies to improve future ARDS trials: the development of new methods to target treatable traits in clinical trial populations, and improvements in the representativeness of ARDS trials, with the inclusion of global populations. We emphasise that these two strategies are complementary. We also discuss how a proposed expansion of the definition of ARDS could affect the future of clinical trials.
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Affiliation(s)
- Katherine D Wick
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
| | - Neil R Aggarwal
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado, Aurora, CO, USA; National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Martha A Q Curley
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Alpha A Fowler
- Division of Pulmonary Disease and Critical Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Samir Jaber
- University Hospital, CHU de Montpellier Hôpital Saint Eloi, Intensive Care Unit and Transplantation, Department of Anesthesiology DAR B, Montpellier, France
| | - Maciej Kostrubiec
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Nathalie Lassau
- Department of Imaging, Gustave Roussy, Université Paris Saclay, Villejuif, France; Biomaps, UMR1281 INSERM, CEA, CNRS, Université Paris Saclay, Villejuif, France
| | - Pierre François Laterre
- Intensive Care Medicine, Saint-Luc University Hospital, Université Catholique de Louvain, Brussels, Belgium
| | - Guillaume Lebreton
- Institute of Cardiometabolism and Nutrition, Inserm, UMRS 1166-ICAN, Sorbonne University, Paris, France; Cardiac Surgery Service, Institute of Cardiology, AP-HP, Sorbonne University, Paris, France
| | - Joseph E Levitt
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, Paris, France
| | | | - Pratik Sinha
- Department of Anesthesiology, Washington University in St Louis, St Louis, MO, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA; Departments of Medicine and Anesthesia, University of California, San Francisco, CA, USA.
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Krutsinger DC, Yadav KN, Harhay MO, Bartels K, Courtright KR. A systematic review and meta-analysis of enrollment into ARDS and sepsis trials published between 2009 and 2019 in major journals. Crit Care 2021; 25:392. [PMID: 34781998 PMCID: PMC8591428 DOI: 10.1186/s13054-021-03804-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Enrollment problems are common among randomized controlled trials conducted in the ICU. However, little is known about actual trial enrollment rates and influential factors. We set out to determine the overall enrollment rate in recent randomized controlled trials (RCTs) of patients with acute respiratory distress syndrome (ARDS), acute lung injury (ALI), or sepsis, and which factors influenced enrollment rate. METHODS We conducted a systematic review by searching Pubmed using predefined terms for ARDS/ALI and sepsis to identify individually RCTs published among the seven highest impact general medicine and seven highest impact critical care journals between 2009 and 2019. Cluster randomized trials were excluded. Data were extracted by two independent reviewers using an electronic database management system. We conducted a random-effects meta-analysis of the eligible trials for the primary outcome of enrollment rate by time and site. RESULTS Out of 457 articles identified, 94 trials met inclusion criteria. Trials most commonly evaluated pharmaceutical interventions (53%), were non-industry funded (78%), and required prospective informed consent (81%). The overall mean enrollment rate was 0.83 (95% confidence interval: 0.57-1.21) participants per month per site. Enrollment in ARDS/ALI and sepsis trials were 0.48 (95% CI 0.32-0.70) and 0.98 (95% CI 0.62-1.56) respectively. The enrollment rate was significantly higher for single-center trials (4.86; 95% CI 2.49-9.51) than multicenter trials (0.52; 95% CI 0.41-0.66). Of the 36 trials that enrolled < 95% of the target sample size, 8 (22%) reported slow enrollment as the reason. CONCLUSIONS In this systematic review and meta-analysis, recent ARDS/ALI and sepsis clinical trials had an overall enrollment rate of less than 1 participant per site per month. Novel approaches to improve critical care trial enrollment efficiency are needed to facilitate the translation of best evidence into practice.
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Affiliation(s)
- Dustin C. Krutsinger
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Nebraska Medical Center, 985910 NE Medical Center, Omaha, NE 68198 USA
| | - Kuldeep N. Yadav
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, 300 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104 USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Michael O. Harhay
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, 300 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104 USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Karsten Bartels
- Department of Anesthesiology, University of Nebraska Medical Center, 985910 NE Medical Center, Omaha, NE 68198 USA
| | - Katherine R. Courtright
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, 300 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104 USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
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Lane T, Sottile PD, Peterson R, Jin Y, Moss M. Significant Variability in Surrogate Informed Consent Rates in ARDS and Prevention and Early Treatment of Acute Lung Injury Network Multicenter Trials. Chest 2021; 161:1306-1309. [PMID: 34543666 PMCID: PMC8552548 DOI: 10.1016/j.chest.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 09/01/2021] [Accepted: 09/06/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Trevor Lane
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Ryan Peterson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ying Jin
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
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Krutsinger DC, Courtright KR, Estabrooks PA. Historic Abuses, Present Disparities, and Systemic Racism: Threats to Surrogate Decision-making for Critical Care Research Enrollment. Ann Am Thorac Soc 2021; 18:1118-1120. [PMID: 34242151 PMCID: PMC8328362 DOI: 10.1513/annalsats.202103-386ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Katherine R Courtright
- Palliative and Advanced Illness Research (PAIR) Center
- Department of Biostatistics, Epidemiology, and Informatics, and
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul A Estabrooks
- Department of Health Promotion; and
- Center for Reducing Health Disparities, University of Nebraska Medical Center, Omaha, Nebraska; and
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