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Largent EA, Joffe S, Dickert NW, Morain SR. The ethical value of consulting community members in non-emergency trials conducted with waivers of informed consent for research. Clin Trials 2024:17407745241259360. [PMID: 38916109 DOI: 10.1177/17407745241259360] [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] [Indexed: 06/26/2024]
Abstract
There is growing interest in using embedded research methods, particularly pragmatic clinical trials, to address well-known evidentiary shortcomings afflicting the health care system. Reviews of pragmatic clinical trials published between 2014 and 2019 found that 8.8% were conducted with waivers of informed consent; furthermore, the number of trials where consent is not obtained is increasing with time. From a regulatory perspective, waivers of informed consent are permissible when certain conditions are met, including that the study involves no more than minimal risk, that it could not practicably be carried out without a waiver, and that waiving consent does not violate participants' rights and welfare. Nevertheless, when research is conducted with a waiver of consent, several ethical challenges arise. We must consider how to: address empirical evidence showing that patients and members of the public generally prefer prospective consent, demonstrate respect for persons using tools other than consent, promote public trust and investigator integrity, and ensure an adequate level of participant protections. In this article, we use examples drawn from real pragmatic clinical trials to argue that prospective consultation with representatives of the target study population can address, or at least mitigate, many of the ethical challenges posed by waivers of informed consent. We also consider what consultation might involve to illustrate its feasibility and address potential objections.
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Affiliation(s)
- Emily A Largent
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Neal W Dickert
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Stephanie R Morain
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
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2
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Wendler D. Pediatric Research without Parental Permission. J Pediatr 2023; 273:113896. [PMID: 38154520 DOI: 10.1016/j.jpeds.2023.113896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 12/30/2023]
Affiliation(s)
- David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, MD.
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Strayer TE, Hollingsworth EK, Shah AS, Vasilevskis EE, Simmons SF, Mixon AS. Why do older adults decline participation in research? Results from two deprescribing clinical trials. Trials 2023; 24:456. [PMID: 37464431 PMCID: PMC10353211 DOI: 10.1186/s13063-023-07506-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 07/10/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Heterogenous older adult populations are underrepresented in clinical trials, and their participation is necessary for interventions that directly target them. The purpose of this study was to evaluate reasons why hospitalized older adults declined participation in two deprescribing clinical trials. METHODS We report enrollment data from two deprescribing trials, Shed-MEDS (non-Veterans) and VA DROP (Veterans). For both trials, inclusion criteria required participants to be hospitalized, age 50 or older, English-speaking, and taking five or more home medications. Eligible patients were approached for enrollment while hospitalized. When an eligible patient or surrogate declined participation, the reason(s) were recorded and subsequently analyzed inductively to develop themes, and a chi-square test was used for comparison (of themes between Veterans and non-Veterans). RESULTS Across both trials, 1226 patients (545 non-Veterans and 681 Veterans) declined enrollment and provided reasons, which were condensed into three themes: (1) feeling overwhelmed by their current health status, (2) lack of interest or mistrust of research, and (3) hesitancy to participate in a deprescribing study. A greater proportion of Veterans expressed a lack of interest or mistrust in research (42% vs 26%, chi-square value = 36.72, p < .001), whereas a greater proportion of non-Veterans expressed feeling overwhelmed by their current health status (54% vs 35%, chi-square value = 42.8 p < 0.001). Across both trials, similar proportion of patients expressed hesitancy to participate in a deprescribing study, with no significant difference between Veterans and non-Veterans (23% and 21%). CONCLUSIONS Understanding the reasons older adults decline participation can inform future strategies to engage this multimorbid population.
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Affiliation(s)
- Thomas E Strayer
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA.
- Division of Geriatrics, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA.
| | - Emily K Hollingsworth
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Division of Geriatrics, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
| | - Avantika S Shah
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Eduard E Vasilevskis
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, 1310 24Th Ave. S, Nashville, TN, 37212, USA
- Section of Hospital Medicine, Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, 2525 West End Ave. Suite 450, Nashville, TN, 37203, USA
| | - Sandra F Simmons
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Division of Geriatrics, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, 1310 24Th Ave. S, Nashville, TN, 37212, USA
| | - Amanda S Mixon
- Center for Quality Aging, Vanderbilt University Medical Center, 2147 Belcourt Ave., Nashville, TN, 37212, USA
- Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, 1310 24Th Ave. S, Nashville, TN, 37212, USA
- Section of Hospital Medicine, Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, 2525 West End Ave. Suite 450, Nashville, TN, 37203, USA
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Patient responses to passive enrollment into a large, pragmatic clinical trial: A qualitative content analysis. Contemp Clin Trials 2022; 121:106925. [PMID: 36108887 DOI: 10.1016/j.cct.2022.106925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 09/01/2022] [Accepted: 09/08/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND While passive enrollment or "opt-out" recruitment methods facilitate pragmatic clinical trials, they pose unique challenges, and it is unclear how participants feel about them. Here, we describe patient responses to passive enrollment into the Watch the Spot Trial, a pragmatic trial comparing two sets of guidelines for small lung nodule follow-up. METHODS For this nested qualitative study, we analyzed participant-initiated calls and emails. We performed a qualitative content analysis, using a team-coding approach to identify reasons that eligible participants contacted the study team. We calculated the proportion of contacts containing each code, and how often each code coincided with study opt-outs and other codes. RESULTS Of 23,412 eligible participants across seven sites, 1494 (6.4%) contacted the study team, with 1560 total contacts. Among the total contacts, the most common codes (i.e., reasons for contacting the team) were study opt-outs (n = 614, 39.0%), clarification of study procedures (n = 328, 21.0%), and unawareness of the nodule prior to research notification (n = 244, 15.6%). The least common codes were concerns about sharing of protected health information with the study team (n = 22, 1.4%) or outside of the healthcare system (n = 26, 1.7%), and disapproval of the opt-out approach (n = 10, 0.6%); most patients with these concerns opted-out. Nodule unawareness sometimes coincided with anger (n = 24) or distress (n = 15), and questions about nodule care sometimes coincided with distress (n = 20) and questions about follow-up surveys (n = 26). CONCLUSION Most participants did not report concerns about passive enrollment. Patient perspectives are an invaluable resource for minimizing risks and inconveniences of future pragmatic trials using this recruitment method.
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McLennan S, Rachut S, Lange J, Fiske A, Heckmann D, Buyx A. Practices and attitudes of Bavarian stakeholders regarding the secondary-use of health data for research purposes during the COVID-19 pandemic: a qualitative interview study (Preprint). J Med Internet Res 2022; 24:e38754. [PMID: 35696598 PMCID: PMC9239567 DOI: 10.2196/38754] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/28/2022] [Accepted: 05/29/2022] [Indexed: 01/14/2023] Open
Abstract
Background The COVID-19 pandemic is a threat to global health and requires collaborative health research efforts across organizations and countries to address it. Although routinely collected digital health data are a valuable source of information for researchers, benefiting from these data requires accessing and sharing the data. Health care organizations focusing on individual risk minimization threaten to undermine COVID-19 research efforts, and it has been argued that there is an ethical obligation to use the European Union’s General Data Protection Regulation (GDPR) scientific research exemption during the COVID-19 pandemic to support collaborative health research. Objective This study aims to explore the practices and attitudes of stakeholders in the German federal state of Bavaria regarding the secondary use of health data for research purposes during the COVID-19 pandemic, with a specific focus on the GDPR scientific research exemption. Methods Individual semistructured qualitative interviews were conducted between December 2020 and January 2021 with a purposive sample of 17 stakeholders from 3 different groups in Bavaria: researchers involved in COVID-19 research (n=5, 29%), data protection officers (n=6, 35%), and research ethics committee representatives (n=6, 35%). The transcripts were analyzed using conventional content analysis. Results Participants identified systemic challenges in conducting collaborative secondary-use health data research in Bavaria; secondary health data research generally only happens when patient consent has been obtained, or the data have been fully anonymized. The GDPR research exemption has not played a significant role during the pandemic and is currently seldom and restrictively used. Participants identified 3 key groups of barriers that led to difficulties: the wider ecosystem at many Bavarian health care organizations, legal uncertainty that leads to risk-adverse approaches, and ethical positions that patient consent ought to be obtained whenever possible to respect patient autonomy. To improve health data research in Bavaria and across Germany, participants wanted greater legal certainty regarding the use of pseudonymized data for research purposes without the patient’s consent. Conclusions The current balance between enabling the positive goals of health data research and avoiding associated data protection risks is heavily skewed toward avoiding risks; so much so that it makes reaching the goals of health data research extremely difficult. This is important, as it is widely recognized that there is an ethical imperative to use health data to improve care. The current approach also creates a problematic conflict with the ambitions of Germany, and the federal state of Bavaria, to be a leader in artificial intelligence. A recent development in the field of German public administration known as norm screening (Normenscreening) could potentially provide a systematic approach to minimize legal barriers. This approach would likely be beneficial to other countries.
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Affiliation(s)
- Stuart McLennan
- Institute of History and Ethics in Medicine, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Sarah Rachut
- TUM Center for Digital Public Services, Department Governance, TUM School of Social Sciences and Technology, Technical University of Munich, Munich, Germany
| | - Johannes Lange
- Institute of History and Ethics in Medicine, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Amelia Fiske
- Institute of History and Ethics in Medicine, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Dirk Heckmann
- TUM Center for Digital Public Services, Department Governance, TUM School of Social Sciences and Technology, Technical University of Munich, Munich, Germany
| | - Alena Buyx
- Institute of History and Ethics in Medicine, TUM School of Medicine, Technical University of Munich, Munich, Germany
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Normand MP, Donohue HE. Research Ethics for Behavior Analysts in Practice. Behav Anal Pract 2022; 16:13-22. [PMID: 37006418 PMCID: PMC10050523 DOI: 10.1007/s40617-022-00698-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 01/10/2023] Open
Abstract
Behavior analysts in practice have an advantage over many others in the helping professions-they have at their disposal a robust science of behavior change informed primarily by single-case experimental research designs. This is advantageous because the research literature is focused on individual behavior change and has direct relevance to behavior analysts who need to change the behavior of individuals in need. Also, the same experimental designs used to advance the basic and applied sciences can be used to evaluate and refine specific procedures as they are put into practice. Thus, behavior-analytic research and practice are often intertwined. However, when behavior analysts in practice conduct research and use their own clients as participants, several important ethical issues need to be considered. Research with human participants is subject to careful ethical oversight, but the ethical guidelines that have been developed are usually described in terms of research conducted by nonpractitioners working in universities or institutions. This article focuses on several areas of special concern when conducting research in practice settings, including dual relationships and conflicts of interest, obtaining informed consent, and using ethical review panels.
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Affiliation(s)
- Matthew P. Normand
- Department of Psychology, University of the Pacific, 3601 Pacific Avenue, Stockton, CA 95211 USA
| | - Hailey E. Donohue
- Department of Psychology, University of the Pacific, 3601 Pacific Avenue, Stockton, CA 95211 USA
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Duenas DM, Shipman KJ, Porter KM, Shuster E, Guerra C, Reyes A, Kauffman TL, Hunter JE, Goddard KAB, Wilfond BS, Kraft SA. Motivations and concerns of patients considering participation in an implementation study of a hereditary cancer risk assessment program in diverse primary care settings. Genet Med 2022; 24:610-621. [PMID: 34906471 PMCID: PMC8939763 DOI: 10.1016/j.gim.2021.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/17/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Understanding the motivations and concerns of patients from diverse populations regarding participation in implementation research provides the needed evidence about how to design and conduct studies for facilitating access to genetics services. Within a hereditary cancer screening study assessing a multifaceted intervention, we examined primary care patients' motivations and concerns about participation. METHODS We surveyed and interviewed study participants after they enrolled, surveyed those who did not complete enrollment, and used descriptive qualitative and quantitative methods to identify motivations and concerns regarding participation. RESULTS Survey respondents' most common motivations included a desire to learn about their future risk (81%), receiving information that may help family (58%), and a desire to advance research (34%). Interviews revealed 3 additional important factors: affordability of testing, convenience of participation, and clinical relationships supporting research decision-making. Survey data of those who declined enrollment showed that the reasons for declining included concerns about privacy (38%), burdens of the research (19%), and their fear of not being able to cope with the genetic information (19%). CONCLUSION Understanding the facilitating factors and concerns that contribute to decisions about research may reveal ways to improve equity in access to care and research that could lead to greater uptake of genomic medicine across diverse primary care patient populations.
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Affiliation(s)
- Devan M Duenas
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA.
| | - Kelly J Shipman
- Palliative Care and Resilience Research Program, Seattle Children's Hospital and Research Institute, Seattle, WA
| | - Kathryn M Porter
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA
| | - Elizabeth Shuster
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Claudia Guerra
- Department of Anthropology, History and Social Medicine, University of California San Francisco, San Francisco, CA
| | - Ana Reyes
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Tia L Kauffman
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | | | - Katrina A B Goddard
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA; Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
| | - Stephanie A Kraft
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA; Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
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Carpenter JG, Ulrich C, Hodgson N, Hanson LC, Ersek M. Alternative Consent Models in Pragmatic Palliative Care Clinical Trials. J Pain Symptom Manage 2021; 62:183-191. [PMID: 33129936 PMCID: PMC8108441 DOI: 10.1016/j.jpainsymman.2020.09.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 01/14/2023]
Abstract
Palliative care research raises a host of ethical concerns. Obtaining informed consent from seriously ill patients and their families is often perceived as an additional burden. Alternative approaches to traditional written informed consent reflect the changing nature of modern trial design, embracing real-world effectiveness and pragmatic clinical trials with those who are seriously ill. Ethicists, clinical investigators, and regulatory bodies have acknowledged the challenges to rigorous, meaningful, and generalizable research across diverse patient populations in real-world settings. The purpose of this article is to describe how these clinical trial designs have driven innovation in methods for achieving informed consent, with a focus on palliative care research. In this article, we describe and provide examples of consent waivers and three types of alternative approaches to consent, including broadcast notification and integrated and targeted consent. We also present our experiences in an ongoing palliative care clinical trial, specifically using broadcast notification. Working with participants and regulatory oversight organizations, investigators can address the limits of traditional written informed consent and adopt innovative consent models to advance the science of palliative care. Research is now needed to determine the impact of these differing consent models on clinical trial recruitment, enrollment, and retention, as well as participants' informed understanding of their research participation using such models.
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Affiliation(s)
- Joan G Carpenter
- University of Maryland School of Nursing, Baltimore, Maryland, USA; Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA.
| | - Connie Ulrich
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nancy Hodgson
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
| | - Laura C Hanson
- Division of Geriatric Medicine & Palliative Care Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Mary Ersek
- Veteran Experience Center, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA; Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Morain SR, Largent EA. Public Attitudes toward Consent When Research Is Integrated into Care-Any "Ought" from All the "Is"? Hastings Cent Rep 2021; 51:22-32. [PMID: 33840104 DOI: 10.1002/hast.1242] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Research that is integrated into ongoing clinical activities holds the potential to accelerate the generation of knowledge to improve the health of individuals and populations. Yet integrating research into clinical care presents difficult ethical and regulatory challenges, including how or whether to obtain informed consent. Multiple empirical studies have explored patients' and the public's attitudes toward approaches to consent for pragmatic research. Questions remain, however, about how to use the resulting empirical data in resolving normative and policy debates and what kind of data warrants the most consideration. We recommend prioritizing data about what people consider acceptable with respect to consent for pragmatic research and data about people's informed, rather than initial, preferences on this subject. In addition, we advise caution regarding the weight given to majority viewpoints and identify circumstances when empirical data can be overridden. We argue that empirical data bolster normative arguments that alterations of consent should be the default in pragmatic research; waivers are appropriate only when the pragmatic research would otherwise be impracticable and has sufficiently high social value.
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Tosoni S, Voruganti I, Lajkosz K, Habal F, Murphy P, Wong RKS, Willison D, Virtanen C, Heesters A, Liu FF. The use of personal health information outside the circle of care: consent preferences of patients from an academic health care institution. BMC Med Ethics 2021; 22:29. [PMID: 33761938 PMCID: PMC7992944 DOI: 10.1186/s12910-021-00598-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 03/04/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Immense volumes of personal health information (PHI) are required to realize the anticipated benefits of artificial intelligence in clinical medicine. To maintain public trust in medical research, consent policies must evolve to reflect contemporary patient preferences. METHODS Patients were invited to complete a 27-item survey focusing on: (a) broad versus specific consent; (b) opt-in versus opt-out approaches; (c) comfort level sharing with different recipients; (d) attitudes towards commercialization; and (e) options to track PHI use and study results. RESULTS 222 participants were included in the analysis; 83% were comfortable sharing PHI with researchers at their own hospital, although younger patients (≤ 49 years) were more uncomfortable than older patients (50 + years; 13% versus 2% uncomfortable, p < 0.05). While 56% of patients preferred broad consent, 38% preferred specific consent; 6% preferred not sharing at all. The majority of patients (63%) preferred to be asked for permission before entry into a contact pool. Again, this trend was more pronounced for younger patients (≤ 49 years: 76%). Approximately half of patients were uncomfortable sharing PHI with commercial enterprises (51% uncomfortable, 27% comfortable, 22% neutral). Most patients preferred to track PHI usage (61%), with the highest proportion once again reported by the youngest patients (≤ 49 years: 71%). A majority of patients also wished to be notified regarding study results (70%). CONCLUSIONS While most patients were willing to share their PHI with researchers within their own institution, many preferred a transparent and reciprocal consent process. These data also suggest a generational shift, wherein younger patients preferred more specific consent options. Modernizing consent policies to reflect increased autonomy is crucial in fostering sustained public engagement with medical research.
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Affiliation(s)
- Sarah Tosoni
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Indu Voruganti
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Katherine Lajkosz
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Flavio Habal
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Patricia Murphy
- Department of Anaesthesia, University Health Network, Toronto, ON, Canada
| | - Rebecca K S Wong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Donald Willison
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Carl Virtanen
- University Health Network Digital, Toronto, ON, Canada
| | - Ann Heesters
- Department of Bioethics, University Health Network, Toronto, ON, Canada
- Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Fei-Fei Liu
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.
- Princess Margaret Cancer Centre, Department of Radiation Oncology, 700 University Avenue, Toronto, ON, M5G 2M9, Canada.
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Cumyn A, Dault R, Barton A, Cloutier AM, Ethier JF. Citizens, Research Ethics Committee Members and Researchers' Attitude Toward Information and Consent for the Secondary Use of Health Data: Implications for Research Within Learning Health Systems. J Empir Res Hum Res Ethics 2021; 16:165-178. [PMID: 33710932 PMCID: PMC8236664 DOI: 10.1177/1556264621992214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A survey was conducted to assess citizens, research ethics committee members, and researchers' attitude toward information and consent for the secondary use of health data for research within learning health systems (LHSs). Results show that the reuse of health data for research to advance knowledge and improve care is valued by all parties; consent regarding health data reuse for research has fundamental importance particularly to citizens; and all respondents deemed important the existence of a secure website to support the information and consent processes. This survey was part of a larger project that aims at exploring public perspectives on alternate approaches to the current consent models for health data reuse to take into consideration the unique features of LHSs. The revised model will need to ensure that citizens are given the opportunity to be better informed about upcoming research and have their say, when possible, in the use of their data.
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Affiliation(s)
- Annabelle Cumyn
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,Département de Médecine, Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Roxanne Dault
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,Département de Médecine, Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,Data Access Component, Quebec SPOR Support Unit, 98629Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Adrien Barton
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,27051Centre National de la Recherche Scientifique-Institut de Recherche en Informatique de Toulouse (CNRS-IRIT), Toulouse, Île-de-France, France
| | - Anne-Marie Cloutier
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,Département de Médecine, Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,Data Access Component, Quebec SPOR Support Unit, 98629Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Jean-François Ethier
- Groupe de Recherche Interdisciplinaire en Informatique de la Santé (GRIIS), Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,Département de Médecine, Faculté de Médecine et des Sciences de la Santé, 7321Université de Sherbrooke, Sherbrooke, Québec, Canada.,Data Access Component, Quebec SPOR Support Unit, 98629Université de Sherbrooke, Sherbrooke, Québec, Canada
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Pickering D, Blaszczynski A. Paid online convenience samples in gambling studies: questionable data quality. INTERNATIONAL GAMBLING STUDIES 2021. [DOI: 10.1080/14459795.2021.1884735] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Dylan Pickering
- School of Psychology, Faculty of Science, The University of Sydney, Camperdown, Australia
| | - Alex Blaszczynski
- School of Psychology, Faculty of Science, The University of Sydney, Camperdown, Australia
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13
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Shearer E, Cho M, Magnus D. Regulatory, social, ethical, and legal issues of artificial intelligence in medicine. Artif Intell Med 2021. [DOI: 10.1016/b978-0-12-821259-2.00023-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Naughton C, Meehan E, Lehane E, Landers C, Flaherty SJ, Lane A, Landers M, Kilty C, Saab M, Goodwin J, Walshe N, Wills T, Mccarthy V, Murphy S, Mccarthy J, Cummins H, Madden D, Hegarty J. Ethical frameworks for quality improvement activities: an analysis of international practice. Int J Qual Health Care 2020; 32:558-566. [DOI: 10.1093/intqhc/mzaa092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 07/29/2020] [Accepted: 08/10/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
Purpose
To examine international approaches to the ethical oversight and regulation of quality improvement and clinical audit in healthcare systems
Data sources
We searched grey literature including websites of national research and ethics regulatory bodies and health departments of selected countries.
Study selection
National guidance documents were included from six countries: Ireland, England, Australia, New Zealand, the United States of America and Canada.
Data extraction
Data were extracted from 19 documents using an a priori framework developed from the published literature.
Results
We organized data under five themes: ethical frameworks; guidance on ethical review; consent, vulnerable groups and personal health data. Quality improvement activity tended to be outside the scope of the ethics frameworks in most countries. Only New Zealand had integrated national ethics standards for both research and quality improvement. Across countries, there is consensus that this activity should not be automatically exempted from ethical review but requires proportionate review or organizational oversight for minimal risk projects. In the majority of countries, there is a lack of guidance on participant consent, use of personal health information and inclusion of vulnerable groups in routine quality improvement.
Conclusion
Where countries fail to provide specific ethics frameworks for quality improvement, guidance is dispersed across several organizations which may lack legal certainty. Our review demonstrates a need for appropriate oversight and responsive infrastructure for quality improvement underpinned by ethical frameworks that build equivalence with research oversight. It outlines aspects of good practice, especially The New Zealand framework that integrates research and quality improvement ethics.
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Affiliation(s)
- Corina Naughton
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Elaine Meehan
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Elaine Lehane
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Ciara Landers
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Sarah Jane Flaherty
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Aoife Lane
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Margaret Landers
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Caroline Kilty
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Mohamad Saab
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - John Goodwin
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Nuala Walshe
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Teresa Wills
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Vera Mccarthy
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Siobhan Murphy
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Joan Mccarthy
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Helen Cummins
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
| | - Deirdre Madden
- School of Law, University College Cork, Aras na Laoi, Cork T12 T656, Ireland
| | - Josephine Hegarty
- Catherine McAuley School of Nursing and Midwifery, University College Cork, College Road, Cork T12 AK54, Ireland
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Abstract
There is intense debate around the use of altered and waived consent for pragmatic trials. Those in favor argue that traditional consent compromises the internal and external validity of these trials. Those against, warn that the resultant loss of autonomy compromises respect for persons and could undermine trust in the research enterprise.This article examines whether international ethical guidelines and the policy frameworks in three countries-the United States, England, and Australia-permit altered and waived consent for minimal-risk pragmatic trials conducted outside the emergency setting. Provisions for both are clearly articulated in U.S. regulations, but many countries do not have equivalent frameworks. Investigators should not assume that all consent models permitted in the United States are legal in their jurisdictions, even if they are deemed ethically defensible.The authors summarize ethical and regulatory considerations and present a framework for investigators contemplating trials with altered or waived consent.
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Hammack-Aviran CM, Brelsford KM, McKenna KC, Graham RD, Lampron ZM, Beskow LM. Research Use of Electronic Health Records: Patients' Views on Alternative Approaches to Permission. AJOB Empir Bioeth 2020; 11:172-186. [PMID: 32338567 DOI: 10.1080/23294515.2020.1755383] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background: The increased use of electronic health records (EHRs) has resulted in new opportunities for research, but also raises concerns regarding privacy, confidentiality, and patient awareness. Because public trust is essential to the success of the research enterprise, patient perspectives are essential to the development and implementation of ethical approaches to the research use of EHRs. Yet, little is known about patients' views and expectations regarding various approaches to seeking permission for research use of their EHR data. Methods: We conducted semi-structured interviews with 120 patients in four counties in diverse regions of the southeastern United States: Appalachia, the Mississippi Delta, and the Piedmont area of North Carolina. We asked participants to consider, from multiple stakeholder perspectives, the advantages and disadvantages of three approaches to notifying patients of, or obtaining permission for, research use of their EHR data; whether they believed it would be acceptable if their healthcare organization used each approach; and which approach would be most appropriate. Results: Nearly all participants said General Notification, Broad Permission, and Categorical Permission would each be acceptable approaches to notification of, or permission for, EHR research. Over half identified Broad Permission as the most appropriate approach. Across all of these discussions, major themes included the importance of clarity, simplicity, and usability of patient-facing materials, as well as the level of transparency, trustworthiness, and respect for patients the approach conveys. Conclusions: Our findings help to inform the development and implementation of ethical approaches to the research use of EHRs by identifying key patient considerations regarding various approaches to permission and suggesting potential actions for healthcare organizations and researchers.
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Affiliation(s)
- Catherine M Hammack-Aviran
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kathleen M Brelsford
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin C McKenna
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ross D Graham
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Zachary M Lampron
- Department of Pragmatic Health Systems Research, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Laura M Beskow
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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17
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Cumyn A, Barton A, Dault R, Cloutier A, Jalbert R, Ethier J. Informed consent within a learning health system: A scoping review. Learn Health Syst 2020; 4:e10206. [PMID: 32313834 PMCID: PMC7156861 DOI: 10.1002/lrh2.10206] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 09/18/2019] [Accepted: 10/08/2019] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION A major consideration for the implementation of a learning health system (LHS) is consent from participants to the use of their data for research purposes. The main objective of this paper was to identify in the literature which types of consent have been proposed for participation in research observational activities in a LHS. We were particularly interested in understanding which approaches were seen as most feasible and acceptable and in which context, in order to inform the development of a Quebec-based LHS. METHODS Using a scoping review methodology, we searched scientific and legal databases as well as the gray literature using specific terms. Full-text articles were reviewed independently by two authors on the basis of the following concepts: (a) LHS and (b) approach to consent. The selected papers were imported in NVivo software for analysis in the light of a conceptual framework that distinguishes various, largely independent dimensions of consent. RESULTS A total of 93 publications were analysed for this review. Several studies reach opposing conclusions concerning the best approach to consent within a LHS. However, in the light of the conceptual framework we developed, we found that many of these results are distorted by the conflation between various characteristics of consent. Thus, when these characteristics are distinguished, the results mainly suggest the prime importance of the communication process, by contrast to the scope of consent or the kind of action required by participants (opt-in/opt-out). We identified two models of consent that were especially relevant for our purpose: metaconsent and dynamic consent. CONCLUSIONS Our review shows the importance of distinguishing carefully the various features of the consent process. It also suggests that the metaconsent model is a valuable model within a LHS, as it addresses many of the issues raised with regards to feasibility and acceptability. We propose to complement this model by adding the modalities of the information process to the dimensions relevant in the metaconsent process.
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Affiliation(s)
- Annabelle Cumyn
- Département de médecine, Faculté de médecine et des sciences de la santéUniversité de SherbrookeQuebecCanada
- Groupe de recherche interdisciplinaire en informatique de la santé (GRIIS), Faculté de médecine et des sciences de la santé/Faculté des sciencesUniversité de SherbrookeQuebecCanada
| | - Adrien Barton
- Groupe de recherche interdisciplinaire en informatique de la santé (GRIIS), Faculté de médecine et des sciences de la santé/Faculté des sciencesUniversité de SherbrookeQuebecCanada
- Centre national de la recherche scientifique ‐ Institut de recherche en informatique de Toulouse (CNRS‐IRIT)ToulouseFrance
| | - Roxanne Dault
- Groupe de recherche interdisciplinaire en informatique de la santé (GRIIS), Faculté de médecine et des sciences de la santé/Faculté des sciencesUniversité de SherbrookeQuebecCanada
| | - Anne‐Marie Cloutier
- Groupe de recherche interdisciplinaire en informatique de la santé (GRIIS), Faculté de médecine et des sciences de la santé/Faculté des sciencesUniversité de SherbrookeQuebecCanada
| | - Rosalie Jalbert
- Groupe de recherche interdisciplinaire en informatique de la santé (GRIIS), Faculté de médecine et des sciences de la santé/Faculté des sciencesUniversité de SherbrookeQuebecCanada
| | - Jean‐François Ethier
- Département de médecine, Faculté de médecine et des sciences de la santéUniversité de SherbrookeQuebecCanada
- Groupe de recherche interdisciplinaire en informatique de la santé (GRIIS), Faculté de médecine et des sciences de la santé/Faculté des sciencesUniversité de SherbrookeQuebecCanada
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18
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Spector-Bagdady K, Krenz CD, Brummel C, Brenner JC, Bradford CR, Shuman AG. "My Research Is Their Business, but I'm Not Their Business": Patient and Clinician Perspectives on Commercialization of Precision Oncology Data. Oncologist 2020; 25:620-626. [PMID: 32167617 DOI: 10.1634/theoncologist.2019-0863] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/14/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Genetic sequencing and precision oncology have supported clinical breakthroughs but depend upon access to vast arrays of research specimens and data. One way for academic medical centers to fund such infrastructure and research is "commercialization" of access to specimens and data to industry. Here we explore patient and clinician perspectives regarding cancer specimen and data commercialization with the goal of improving such processes in the future. MATERIALS AND METHODS This qualitative analysis was embedded within a prospective precision oncology sequencing study of adults with head and neck cancer. Via semistructured dyadic interviews with patients with cancer and their doctors, we assessed understanding and concerns regarding potential commercialization, opinions regarding investment of profits, and perspectives regarding the return of information directly to participants from industry. RESULTS Several patient- and clinician-participants did not understand that the consent form already permitted commercialization of patient genetic data and expressed concerns regarding who would profit from the data, how profits would be used, and privacy and access. Patients were generally more comfortable with commercialization than clinicians. Many patients and clinicians were comfortable with investing profits back into research, but clinicians were more interested in investment in head and neck cancer research specifically. Patients generally supported potential return-of-results from a private entity, but their clinicians were more skeptical. CONCLUSION Our results illustrate the limitations of mandatory disclosures in the informed consent process. The voices of both patients and their doctors are critical to mitigate violations of privacy and a degradation of trust as stakeholders negotiate the terms of academic and commercial engagement. IMPLICATIONS FOR PRACTICE Further education is needed regarding how and why specimens and data in precision oncology research may be commercialized for both patients and providers alike. This process will require increased transparency, comprehension, and engagement of involved stakeholders.
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Affiliation(s)
- Kayte Spector-Bagdady
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Center for Bioethics & Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Chris D Krenz
- Center for Bioethics & Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Collin Brummel
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - J Chad Brenner
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Carol R Bradford
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Andrew G Shuman
- Center for Bioethics & Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Otolaryngology - Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
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19
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Nicholls SG, Carroll K, Zwarenstein M, Brehaut JC, Weijer C, Hey SP, Goldstein CE, Graham ID, Grimshaw JM, McKenzie JE, Fergusson DA, Taljaard M. The ethical challenges raised in the design and conduct of pragmatic trials: an interview study with key stakeholders. Trials 2019; 20:765. [PMID: 31870433 PMCID: PMC6929346 DOI: 10.1186/s13063-019-3899-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/08/2019] [Indexed: 12/20/2022] Open
Abstract
Background There is a concern that the apparent effectiveness of interventions tested in clinical trials may not be an accurate reflection of their actual effectiveness in usual practice. Pragmatic randomized controlled trials (RCTs) are designed with the intent of addressing this discrepancy. While pragmatic RCTs may increase the relevance of research findings to practice they may also raise new ethical concerns (even while reducing others). To explore this question, we interviewed key stakeholders with the aim of identifying potential ethical challenges in the design and conduct of pragmatic RCTs with a view to developing future guidance on these issues. Methods Interviews were conducted with clinical investigators, methodologists, patient partners, ethicists, and other knowledge users (e.g., regulators). Interviews covered experiences with pragmatic RCTs, ethical issues relevant to pragmatic RCTs, and perspectives on the appropriate oversight of pragmatic RCTs. Interviews were coded inductively by two coders. Interim and final analyses were presented to the broader team for comment and discussion before the analytic framework was finalized. Results We conducted 45 interviews between April and September 2018. Interviewees represented a range of disciplines and jurisdictions as well as varying content expertise. Issues of importance in pragmatic RCTs were (1) identification of relevant risks from trial participation and determination of what constitutes minimal risk; (2) determining when alterations to traditional informed consent approaches are appropriate; (3) the distinction between research, quality improvement, and practice; (4) the potential for broader populations to be affected by the trial and what protections they might be owed; (5) the broader range of trial stakeholders in pragmatic RCTs, and determining their roles and responsibilities; and (6) determining what constitutes “usual care” and implications for trial reporting. Conclusions Our findings suggest both the need to discuss familiar ethical topics in new ways and that there are new ethical issues in pragmatic RCTs that need greater attention. Addressing the highlighted issues and developing guidance will require multidisciplinary input, including patient and community members, within a broader and more comprehensive analysis that extends beyond consent and attends to the identified considerations relating to risk and stakeholder roles and responsibilities.
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Affiliation(s)
- Stuart G Nicholls
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.
| | - Kelly Carroll
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Jamie C Brehaut
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Spencer P Hey
- Center for Bioethics, Harvard Medical School and Program on Regulation, Therapeutics, and Law at Brigham and Women's Hospital, Boston, MA, USA
| | - Cory E Goldstein
- Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Ian D Graham
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Department of Medicine University of Ottawa, Ottawa Hospital Research Institute (OHRI), ON, Ottawa, Canada
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dean A Fergusson
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Department of Medicine University of Ottawa, Ottawa Hospital Research Institute (OHRI), ON, Ottawa, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program-Ottawa Hospital Research Institute (OHRI), Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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20
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Hodson J, Garros C, Jensen J, Duff JP, Garcia Guerra G, Joffe AR. Parental opinions regarding consent for observational research of no or minimal risk in the pediatric intensive care unit. J Intensive Care 2019; 7:60. [PMID: 31890222 PMCID: PMC6916229 DOI: 10.1186/s40560-019-0411-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/31/2019] [Indexed: 11/24/2022] Open
Abstract
Background The aim of the study was to determine opinions and knowledge regarding the process of obtaining informed consent to participate in observational research in pediatric intensive care. Methods Survey 1 asked decision makers what model(s) of consent was acceptable for each type of observational research both before and after background information. Survey 2 asked decision makers about the experience of being asked for consent to observational research, and knowledge regarding the consent process both before and after background information. Results Cooperation rate was 100/117 (85%). The proportion in favor of any of the offered alternatives to signed informed consent for observational research, after receiving all the background information, was 74-80%, lowest for observational prospective research with a minimal risk intervention 37/50 (74%; 95% CI 60–84%). The proportion who agreed they felt overwhelmed by being approached for consent to observational research was 26 (52%; 95% CI 39-65%). Most respondents (from 60 to 74%) felt they understood the concepts regarding observational research; however, after reading background information, most (from 60 to 74%) felt their understanding had improved “a great deal”. Conclusion Understanding of risk, practical difficulties, consent bias, and Research Ethics Board safeguards was poor. Future study is needed to confirm our finding that most agreed with alternative methods of consent for observational research.
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Affiliation(s)
- Jessica Hodson
- 1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, Alberta Canada
| | - Christiana Garros
- 1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, Alberta Canada
| | - Jodie Jensen
- 1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, Alberta Canada
| | - Jonathan P Duff
- 1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, Alberta Canada
| | - Gonzalo Garcia Guerra
- 1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, Alberta Canada
| | - Ari R Joffe
- 1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stollery Children's Hospital and University of Alberta, Edmonton, Alberta Canada.,4-546 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, AB T6G 1C9 Canada.,3John Dossetor Health Ethics Center, University of Alberta, Edmonton, Alberta Canada
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21
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Kim JP, Ryan K, Roberts LW. Attitudes Regarding Enrollment in a Genetic Research Project: An Informed Consent Simulation Study Comparing Views of People With Depression, Diabetes, and Neither Condition. J Empir Res Hum Res Ethics 2019; 14:328-337. [PMID: 31328612 PMCID: PMC6733621 DOI: 10.1177/1556264619862467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this study, participants with a self-reported history of depression, diabetes, or no illness underwent a simulated informed consent process for a hypothetical genetic study related to depression or diabetes. Participants completed a survey assessing their perceived understanding of the research process, perceptions of its risks and benefits, their satisfaction with the informed consent process, and their readiness to make a hypothetical enrollment decision. All participants indicated strong readiness to make an enrollment decision regarding the research characterized in the simulation. Participants reported understanding the consent process relatively well and being generally satisfied with it. Greater concerns were expressed regarding psychosocial risks than biological risks for genetic studies on mental disorders. Our study documented positive attitudes toward volunteering for research that involved the collection of genetic data.
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Affiliation(s)
| | - Katie Ryan
- Stanford University School of Medicine (USA)
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22
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Morain SR, Majumder MA, McGuire AL. Learning Health System - Moving from Ethical Frameworks to Practical Implementation. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2019; 47:454-458. [PMID: 31560628 DOI: 10.1177/1073110519876180] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Stephanie R Morain
- Stephanie R. Morain, M.P.H, Ph.D., is an Assistant Professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine. She received an A.B. in Biology and History, Government, and Law from Lafayette College, an M.P.H. from Columbia University, and a Ph.D. from Harvard University. Mary A. Majumder, J.D., Ph.D.,is an Associate Professor of Medicine at the Center for Medical Ethics and Health Policy, Baylor College of Medicine. She received an A.B. from Bryn Mawr College, a J.D. from Yale Law School, and a Ph.D. from Rice. Amy L. McGuire, J.D., Ph.D., is the Leon Jaworski Professor of Biomedical Ethics and Director of the Center for Medical Ethics and Health Policy at Baylor College of Medicine. She received a B.A. in psychology from the University of Pennsylvania, a J.D. from the University of Houston, and a Ph.D. from the Institute for Medical Humanities at the University of Texas Medical Branch
| | - Mary A Majumder
- Stephanie R. Morain, M.P.H, Ph.D., is an Assistant Professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine. She received an A.B. in Biology and History, Government, and Law from Lafayette College, an M.P.H. from Columbia University, and a Ph.D. from Harvard University. Mary A. Majumder, J.D., Ph.D.,is an Associate Professor of Medicine at the Center for Medical Ethics and Health Policy, Baylor College of Medicine. She received an A.B. from Bryn Mawr College, a J.D. from Yale Law School, and a Ph.D. from Rice. Amy L. McGuire, J.D., Ph.D., is the Leon Jaworski Professor of Biomedical Ethics and Director of the Center for Medical Ethics and Health Policy at Baylor College of Medicine. She received a B.A. in psychology from the University of Pennsylvania, a J.D. from the University of Houston, and a Ph.D. from the Institute for Medical Humanities at the University of Texas Medical Branch
| | - Amy L McGuire
- Stephanie R. Morain, M.P.H, Ph.D., is an Assistant Professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine. She received an A.B. in Biology and History, Government, and Law from Lafayette College, an M.P.H. from Columbia University, and a Ph.D. from Harvard University. Mary A. Majumder, J.D., Ph.D.,is an Associate Professor of Medicine at the Center for Medical Ethics and Health Policy, Baylor College of Medicine. She received an A.B. from Bryn Mawr College, a J.D. from Yale Law School, and a Ph.D. from Rice. Amy L. McGuire, J.D., Ph.D., is the Leon Jaworski Professor of Biomedical Ethics and Director of the Center for Medical Ethics and Health Policy at Baylor College of Medicine. She received a B.A. in psychology from the University of Pennsylvania, a J.D. from the University of Houston, and a Ph.D. from the Institute for Medical Humanities at the University of Texas Medical Branch
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23
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Santel F, Bah I, Kim K, Lin JA, McCracken J, Teme A. Assessing readability and comprehension of informed consent materials for medical device research: A survey of informed consents from FDA's Center for Devices and Radiological Health. Contemp Clin Trials 2019; 85:105831. [PMID: 31445173 DOI: 10.1016/j.cct.2019.105831] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 10/26/2022]
Abstract
Legally effective informed consent has been a long-standing requirement for FDA-regulated clinical studies. However, informed consent forms (ICFs) are often thought to be too long, too complex, and too difficult for participants to understand. In this article, investigators from the FDAs Center for Devices and Radiological Health (CDRH) surveyed 399 ICFs from approved investigational device exemption (IDE) applications for fiscal years 2015 and 2016 to evaluate the readability of ICFs. The investigators collected data from the ICFs, using variables related to structure, readability, and comprehension. The investigators found that the mean grade-reading levels of the ICFs ranged from 10th grade to college level (Table 2), higher than the recommended 6th to 8th grade level, when measured by major readability evaluation tools (the SMOG readability grade level formula, the Flesch-Kincaid Index Grade Level Readability Formula, the Flesch Reading Ease test, and the Dale-Chall readability formula). Overall, the ICFs and informed consent (IC) processes, as described in the IDE application, lacked components that enhanced participants' comprehension, such as short sentences (e.g., no more than 8 to 10 to words) and the use of pictures, tables, and diagrams. CDRH investigators believe that information about ICFs' readability, comprehension, and structure will help support current and future efforts to improve the IC process. The intent of the article is to demonstrate that improvements are needed in the IC process and to encourage clinical trial stakeholders to consider implementing those approaches that optimize patient comprehension in the development of their IC processes.
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Affiliation(s)
- Fabienne Santel
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD, United States of America.
| | - Isatu Bah
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD, United States of America
| | - Katherine Kim
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD, United States of America
| | - Ja-An Lin
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD, United States of America
| | - Jack McCracken
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD, United States of America
| | - Adaeze Teme
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD, United States of America.
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Dickert NW, Wendler D, Devireddy CM, Goldkind SF, Ko YA, Speight CD, Kim SYH. Consent for Pragmatic Trials in Acute Myocardial Infarction. J Am Coll Cardiol 2019; 71:1051-1053. [PMID: 29495987 DOI: 10.1016/j.jacc.2017.12.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/05/2017] [Accepted: 12/11/2017] [Indexed: 11/19/2022]
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Kraft SA, Garrison NA. An Ethical Case for Dual-Role Consent: Increasing Research Diversity as a Matter of Respect and Justice. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:44-46. [PMID: 31544678 DOI: 10.1080/15265161.2019.1572816] [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]
Affiliation(s)
- Stephanie A Kraft
- University of Washington School of Medicine and Seattle Children's Hospital and Research Institute
| | - Nanibaa' A Garrison
- University of Washington School of Medicine and Seattle Children's Hospital and Research Institute
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Wilfond BS, Porter KM. Justifying Investigator/Clinician Consent When The Physician-Patient Relationship Can Support Better Research Decision-Making. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:26-28. [PMID: 31544673 PMCID: PMC10027386 DOI: 10.1080/15265161.2019.1574496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute and
- University of Washington School of Medicine
| | - Kathryn M Porter
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute and
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Morain SR, Joffe S, Largent EA. When Is It Ethical for Physician-Investigators to Seek Consent From Their Own Patients? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:11-18. [PMID: 30994425 DOI: 10.1080/15265161.2019.1572811] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Classic statements of research ethics advise against permitting physician-investigators to obtain consent for research participation from patients with whom they have preexisting treatment relationships. Reluctance about "dual-role" consent reflects the view that distinct normative commitments govern physician-patient and investigator-participant relationships, and that blurring the research-care boundary could lead to ethical transgressions. However, several features of contemporary research demand reconsideration of the ethics of dual-role consent. Here, we examine three arguments advanced against dual-role consent: that it creates role conflict for the physician-investigator; that it can compromise the voluntariness of the patient-participant's consent; and that it promotes therapeutic misconceptions. Although these concerns have merit in some circumstances, they are not dispositive in all cases. Rather, their force-and the ethical acceptability of dual-role consent-varies with features of the particular study. As research participation more closely approximates usual care, it becomes increasingly acceptable, or even preferable, for physicians to seek consent for research from their own patients. It is time for a more nuanced approach to dual-role consent.
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Affiliation(s)
| | - Steven Joffe
- b University of Pennsylvania Perelman School of Medicine; Children's Hospital of Philadelphia
| | - Emily A Largent
- c University of Pennsylvania Perelman School of Medicine; Leonard Davis Institute of Health Economics
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Menikoff J. How Conducting "Usual Care" Research Might Affect Obtaining Consent. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:1-3. [PMID: 31544668 DOI: 10.1080/15265161.2019.1590037] [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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Dal-Ré R, Avendaño-Solà C, Bloechl-Daum B, de Boer A, Eriksson S, Fuhr U, Holm S, James SK, Mentz RJ, Perucca E, Rosendaal FR, Treweek S. Low risk pragmatic trials do not always require participants' informed consent. BMJ 2019; 364:l1092. [PMID: 30917969 DOI: 10.1136/bmj.l1092] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Rafael Dal-Ré
- Epidemiology Unit, Health Research Institute-Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, Avda Reyes Católicos 2, E-28040 Madrid, Spain
| | - Cristina Avendaño-Solà
- Clinical Pharmacology Service, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain
| | | | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, Netherlands
| | - Stefan Eriksson
- Centre for Research Ethics and Bioethics, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Uwe Fuhr
- Universityof Cologne Faculty of Medicine and University Hospital Cologne Centre of Pharmacology,Department I of Pharmacology, Clinical Pharmacology Unit, Cologne, Germany
| | - Søren Holm
- Centre for Social Ethics and Policy, School of Law, University of Manchester, Manchester, UK
| | - Stefan K James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Robert J Mentz
- Department of Medicine, Duke University Medical Centre and Clinical Research Institute, Durham, NC, USA
| | - Emilio Perucca
- Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Frits R Rosendaal
- Department of Clinical Epidemiology C7-P, Leiden University Medical Center, Leiden, The Netherlands
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Aberdeen , UK
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Mbuthia D, Molyneux S, Njue M, Mwalukore S, Marsh V. Kenyan health stakeholder views on individual consent, general notification and governance processes for the re-use of hospital inpatient data to support learning on healthcare systems. BMC Med Ethics 2019; 20:3. [PMID: 30621693 PMCID: PMC6325859 DOI: 10.1186/s12910-018-0343-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 12/26/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Increasing adoption of electronic health records in hospitals provides new opportunities for patient data to support public health advances. Such learning healthcare models have generated ethical debate in high-income countries, including on the role of patient and public consent and engagement. Increasing use of electronic health records in low-middle income countries offers important potential to fast-track healthcare improvements in these settings, where a disproportionate burden of global morbidity occurs. Core ethical issues have been raised around the role and form of information sharing processes for learning healthcare systems, including individual consent and individual and public general notification processes, but little research has focused on this perspective in low-middle income countries. METHODS We conducted a qualitative study on the role of information sharing and governance processes for inpatient data re-use, using in-depth interviews with 34 health stakeholders at two public hospitals on the Kenyan coast, including health managers, providers and researchers. Data were collected between March and July 2016 and analysed using a framework approach, with Nvivo 10 software to support data management. RESULTS Most forms of clinical data re-use were seen as an important public health good. Individual consent and general notification processes were often argued as important, but contingent on interrelated influences of the type of data, use and secondary user. Underlying concerns were linked to issues of patient privacy and autonomy; perceived risks to trust in health systems; and fairness in how data would be used, particularly for non-public sector re-users. Support for engagement often turned on the anticipated outcomes of information-sharing processes, as building or undermining trust in healthcare systems. CONCLUSIONS As reported in high income countries, learning healthcare systems in low-middle counties may generate a core ethical tension between supporting a public good and respecting patient autonomy and privacy, with the maintenance of public trust acting as a core requirement. While more evidence is needed on patient and public perspectives on learning healthcare activities, greater collaboration between public health and research governance systems is likely to support the development of efficient and locally responsive learning healthcare activities in LMICs.
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Affiliation(s)
- Daniel Mbuthia
- Ujamaa Africa, Kenya, 5th Floor, Landmark Plaza, Kamunde Rd, Nairobi, Kenya
| | - Sassy Molyneux
- KEMRI Wellcome Trust Research Programme, Kilifi, 80108 Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, South Parks Road, Oxford University, Oxford, OX1 3SY UK
| | - Maureen Njue
- Institute for Tropical Medicine, Kronenburgstraat 43, 2000 Antwerpen, Belgium
| | - Salim Mwalukore
- KEMRI Wellcome Trust Research Programme, Kilifi, 80108 Kenya
| | - Vicki Marsh
- KEMRI Wellcome Trust Research Programme, Kilifi, 80108 Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, South Parks Road, Oxford University, Oxford, OX1 3SY UK
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Consent and engagement, security, and authentic living using wearable and mobile health technology. Nat Biotechnol 2019; 35:617-620. [PMID: 28700542 DOI: 10.1038/nbt.3887] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Baker FX, Merz JF. What gives them the right? Legal privilege and waivers of consent for research. Clin Trials 2018; 15:579-586. [PMID: 30280910 DOI: 10.1177/1740774518803122] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Waivers of informed consent for research participation are permitted in the United States under the Common Rule, the Health Insurance Portability and Accountability Act regulations, and the US Food and Drug Administration's Exception from Informed Consent rule for emergency research. We assess the novel question regarding what legal right researchers have to carry out research procedures on or about another person, be it experimental medical intervention, psychological or social manipulation, or invasion of privacy, without the permission of their subjects. Our analysis frames waivers of consent as a species of presumed consent, and we address the underlying empirical question of whether it is reasonable to believe that subjects from whom no consent is sought would in fact agree, if asked. A scoping review of what is known about participation and refusal rates in United States-based research suggests that a large minority, on average, do not agree to take part in research. Refusal rates vary widely. This suggests that, while researchers may assert the social utility of their studies are high enough to justify waivers, there is reason to suspect that many who would be enrolled under a waiver of consent would not want to be enrolled. We conclude that waivers should be rare and that institutional review boards and researchers must explicitly address study acceptability in the community at large and the target population of their proposed research.
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Affiliation(s)
- Francis X Baker
- 1 Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jon F Merz
- 1 Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Dickert NW, Wendler D, Devireddy CM, Goldkind SF, Ko YA, Speight CD, Kim SY. Understanding preferences regarding consent for pragmatic trials in acute care. Clin Trials 2018; 15:567-578. [PMID: 30280582 DOI: 10.1177/1740774518801007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There has been debate about the role of consent in pragmatic trials comparing qualitatively similar interventions. Consent preferences may differ in acute care contexts, given severe illness, time constraints, and other barriers to consent. In addition, studies have not assessed the impact of disclosing financial considerations as a justification for trials. This study was designed to assess preferences of the general public regarding consent for a pragmatic trial in ST-elevation myocardial infarction. METHODS This survey was completed using an online, probability-based panel representative of the US population. It incorporated a randomized, experimental (2 × 2) design assessing (1) preference for written consent versus an alternative (notification after enrollment or brief verbal consent) and (2) impact of including cost as a motivating factor for the trial. The survey used a scenario based on a recent pragmatic trial in ST-elevation myocardial infarction. Primary independent variables were personal preference and recommendation as a member of a review board regarding written consent versus the assigned alternative strategy and personal attitude toward trial enrollment. Descriptive analyses were conducted using post-stratification weights. Regression models were created to examine relationships between demographic variables and consent preference and willingness to enroll. Provision of cost information was incorporated into a regression model to examine its impact on consent preference. RESULTS The study included 2027 participants. Of those participants, 51.1% versus 45.8% stated a personal preference for written consent versus notification after enrollment; however, 60.0% versus 35.5% preferred brief verbal consent to written consent. Even among respondents stating they would be unlikely to enroll in the trial if asked, more respondents (50.6%) preferred brief verbal consent. The preference for verbal consent was generally shared across demographic categories, although lower educational attainment was associated with reduced acceptance (p = 0.001 for trend). Respondents were more likely to support an alternative to written consent when asked their personal preference than when asked their recommendation as a member of a review board. The provision of cost information did not have a meaningful effect on consent preferences, attitudes toward enrollment, or views about the study. CONCLUSION Respondents generally supported prospective involvement in enrollment decisions in the setting of acute myocardial infarction and were particularly supportive of brief verbal consent. This support persisted across demographic categories. The finding that individuals were more likely to support alternatives to written consent when asked for a personal preference rather than as a "committee member" suggests that conservative institutional approaches to consent could hinder implementation of more patient-centered approaches. The role of cost transparency in consent discussions warrants further study.
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Affiliation(s)
- Neal W Dickert
- 1 Division of Cardiology, Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA.,2 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - David Wendler
- 3 Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Chandan M Devireddy
- 1 Division of Cardiology, Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | | | - Yi-An Ko
- 1 Division of Cardiology, Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Candace D Speight
- 1 Division of Cardiology, Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Scott Yh Kim
- 2 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Ethical Implications of Clinical Genomic Information, Records Research, and Informed Consent. Ochsner J 2018; 18:196-198. [PMID: 30275779 DOI: 10.31486/toj.18.0052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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McLennan S, Kahrass H, Wieschowski S, Strech D, Langhof H. The spectrum of ethical issues in a Learning Health Care System: a systematic qualitative review. Int J Qual Health Care 2018; 30:161-168. [PMID: 29394354 DOI: 10.1093/intqhc/mzy005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 01/08/2018] [Indexed: 02/06/2023] Open
Abstract
Purpose To determine systematically the spectrum of ethical issues that is raised for stakeholders in a 'Learning Health Care System' (LHCS). Data sources The systematic review was conducted in PubMed and Google Books between the years 2007 and 2015. Study selection The literature search retrieved 1258 publications. Each publication was independently screened by two reviewers for eligibility for inclusion. Ethical issues were defined as arising when a relevant normative principle is not adequately considered or two principles come into conflict. Data extraction A total of 65 publications were included in the final analysis and were analysed using an adapted version of qualitative content analysis. A coding frame was developed inductively from the data, only the highest-level categories were generated deductively for a life-cycle perspective. Results of data synthesis A total of 67 distinct ethical issues could be categorized under different phases of the LHCS life-cycle. An overarching theme that was repeatedly raised was the conflict between the current regulatory system and learning health care. Conclusion The implementation of a LHCS can help realize the ethical imperative to continuously improve the quality of health care. However, the implementation of a LHCS can also raise a number of important ethical issues itself. This review highlights the importance for health care leaders and policy makers to balance the need to protect and respect individual participants involved in learning health care activities with the social value of improving health care.
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Affiliation(s)
- Stuart McLennan
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.,Institute for Biomedical Ethics, Universität Basel, Bernoullistrasse 28, 4056 Basel, Switzerland
| | - Hannes Kahrass
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Susanne Wieschowski
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Daniel Strech
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Holger Langhof
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, OE 5450, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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Andrews JE, Moore JB, Weinberg RB, Sissine M, Gesell S, Halladay J, Rosamond W, Bushnell C, Jones S, Means P, King NMP, Omoyeni D, Duncan PW. Ensuring respect for persons in COMPASS: a cluster randomised pragmatic clinical trial. JOURNAL OF MEDICAL ETHICS 2018; 44:560-566. [PMID: 29720489 PMCID: PMC6073919 DOI: 10.1136/medethics-2017-104478] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 02/01/2018] [Accepted: 03/21/2018] [Indexed: 06/08/2023]
Abstract
Cluster randomised clinical trials present unique challenges in meeting ethical obligations to those who are treated at a randomised site. Obtaining informed consent for research within the context of clinical care is one such challenge. In order to solve this problem it is important that an informed consent process be effective and efficient, and that it does not impede the research or the healthcare. The innovative approach to informed consent employed in the COMPASS study demonstrates the feasibility of upholding ethical standards without imposing undue burden on clinical workflows, staff members or patients who may participate in the research by virtue of their presence in a cluster randomised facility. The COMPASS study included 40 randomised sites and compared the effectiveness of a postacute stroke intervention with standard care. Each site provided either the comprehensive postacute stroke intervention or standard care according to the randomisation assignment. Working together, the study team, institutional review board and members of the community designed an ethically appropriate and operationally reasonable consent process which was carried out successfully at all randomised sites. This achievement is noteworthy because it demonstrates how to effectively conduct appropriate informed consent in cluster randomised trials, and because it provides a model that can easily be adapted for other pragmatic studies. With this innovative approach to informed consent, patients have access to the information they need about research occurring where they are seeking care, and medical researchers can conduct their studies without ethical concerns or unreasonable logistical impediments. TRIAL REGISTRATION NUMBER NCT02588664, recruiting. This article covers the development of consent process that is currentlty being employed in the study.
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Affiliation(s)
- Joseph E Andrews
- Institutional Review Board, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - J Brian Moore
- Institutional Review Board, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Richard B Weinberg
- Institutional Review Board, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Mysha Sissine
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Sabina Gesell
- Public Health Sciences Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Jacquie Halladay
- Department of Family Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Wayne Rosamond
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Cheryl Bushnell
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Sara Jones
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Paula Means
- Institutional Review Board, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Nancy M P King
- Center for Bioethics, Health, and Society; Public Health Sciences Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Diana Omoyeni
- Institutional Review Board, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Pamela W Duncan
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Kim JP, Roberts LW. The Transition to Precision Psychiatry and Pragmatic Inquiry Methods in Academic Psychiatry: The Example of Point-of-Care Clinical Trials. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2018; 42:529-533. [PMID: 29134550 PMCID: PMC5949248 DOI: 10.1007/s40596-017-0848-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 10/25/2017] [Indexed: 06/07/2023]
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Dal-Ré R, Carné X. Is it time to discuss on low-intervention clinical trials without participants' informed consent? Med Clin (Barc) 2018; 150:345-347. [PMID: 29196035 DOI: 10.1016/j.medcli.2017.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 10/23/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Rafael Dal-Ré
- Unidad de Epidemiología, Instituto de Investigación Sanitaria-Hospital Universitario Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, España.
| | - Xavier Carné
- Servicio de Farmacología Clínica, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departamento de Fundamentos Clínicos, Universidad de Barcelona , Barcelona, España
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Mc Cord KA, Al-Shahi Salman R, Treweek S, Gardner H, Strech D, Whiteley W, Ioannidis JPA, Hemkens LG. Routinely collected data for randomized trials: promises, barriers, and implications. Trials 2018; 19:29. [PMID: 29325575 PMCID: PMC5765645 DOI: 10.1186/s13063-017-2394-5] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 11/29/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Routinely collected health data (RCD) are increasingly used for randomized controlled trials (RCTs). This can provide three major benefits: increasing value through better feasibility (reducing costs, time, and resources), expanding the research agenda (performing trials for research questions otherwise not amenable to trials), and offering novel design and data collection options (e.g., point-of-care trials and other designs directly embedded in routine care). However, numerous hurdles and barriers must be considered pertaining to regulatory, ethical, and data aspects, as well as the costs of setting up the RCD infrastructure. Methodological considerations may be different from those in traditional RCTs: RCD are often collected by individuals not involved in the study and who are therefore blinded to the allocation of trial participants. Another consideration is that RCD trials may lead to greater misclassification biases or dilution effects, although these may be offset by randomization and larger sample sizes. Finally, valuable insights into external validity may be provided when using RCD because it allows pragmatic trials to be performed. METHODS We provide an overview of the promises, challenges, and potential barriers, methodological implications, and research needs regarding RCD for RCTs. RESULTS RCD have substantial potential for improving the conduct and reducing the costs of RCTs, but a multidisciplinary approach is essential to address emerging practical barriers and methodological implications. CONCLUSIONS Future research should be directed toward such issues and specifically focus on data quality validation, alternative research designs and how they affect outcome assessment, and aspects of reporting and transparency.
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Affiliation(s)
- Kimberly A. Mc Cord
- Basel Institute for Clinical Epidemiology and Biostatistics (CEB), Department of Clinical Research, University Hospital Basel, University of Basel, Spitalstrasse 12, 4031 Basel, Switzerland
| | | | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Aberdeen, AB25 2ZD UK
| | - Heidi Gardner
- Health Services Research Unit, University of Aberdeen, Aberdeen, AB25 2ZD UK
| | - Daniel Strech
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, 30625 Hannover, Germany
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH16 4SB UK
| | - John P. A. Ioannidis
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305 USA
- Meta-Research Innovation Center at Stanford (METRICS), Stanford School of Medicine, Palo Alto, CA 94304 USA
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA 94305 USA
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA 94305 USA
- Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, CA 94305 USA
| | - Lars G. Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics (CEB), Department of Clinical Research, University Hospital Basel, University of Basel, Spitalstrasse 12, 4031 Basel, Switzerland
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Dickert NW, Eyal N, Goldkind SF, Grady C, Joffe S, Lo B, Miller FG, Pentz RD, Silbergleit R, Weinfurt KP, Wendler D, Kim SYH. Reframing Consent for Clinical Research: A Function-Based Approach. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:3-11. [PMID: 29148951 DOI: 10.1080/15265161.2017.1388448] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Although informed consent is important in clinical research, questions persist regarding when it is necessary, what it requires, and how it should be obtained. The standard view in research ethics is that the function of informed consent is to respect individual autonomy. However, consent processes are multidimensional and serve other ethical functions as well. These functions deserve particular attention when barriers to consent exist. We argue that consent serves seven ethically important and conceptually distinct functions. The first four functions pertain principally to individual participants: (1) providing transparency; (2) allowing control and authorization; (3) promoting concordance with participants' values; and (4) protecting and promoting welfare interests. Three other functions are systemic or policy focused: (5) promoting trust; (6) satisfying regulatory requirements; and (7) promoting integrity in research. Reframing consent around these functions can guide approaches to consent that are context sensitive and that maximize achievable goals.
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Affiliation(s)
| | - Nir Eyal
- b Harvard University T H Chan School of Public Health
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Comparison of Approaches for Notification and Authorization in Pragmatic Clinical Research Evaluating Commonly Used Medical Practices. Med Care 2017. [PMID: 28650924 DOI: 10.1097/mlr.0000000000000762] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND For pragmatic clinical research comparing commonly used treatments, questions exist about if and how to notify participants about it and secure their authorization for participation. OBJECTIVE To determine how patients react when they seek clinical care and encounter one of several different pragmatic clinical research studies. RESEARCH DESIGN In an online survey using a between-subjects experimental design, respondents read and responded to 1 of 24 hypothetical research scenarios reflecting different types of studies and approaches to notification and authorization (eg, general notification, oral consent, written consent). SUBJECTS English-speaking US adults 18 years and older. MEASURES Willingness to participate in the hypothetical study, acceptability of the notification and authorization approach, understanding of the study, perceptions of benefit/harm, trust, and perception of amount of study information received. RESULTS Willingness to participate did not differ by notification and authorization approach. Some (21%-36%) of the patients randomized to general notification with an explicit opt-out provision were not aware they would be enrolled by default. Acceptability was greatest for and similar among notification and authorization approaches that actively engaged the patient (eg, oral or written consent) and lower for approaches with less engagement (eg, general notification). Problems of understanding were found among 20%-55% of respondents, depending on the particular scenario. Most respondents (77%-94%) felt that participation in the hypothetical study posed no risks of harm to their health or privacy. CONCLUSIONS Current attitudes about notification and authorization approaches and difficulties understanding pragmatic clinical research pose significant challenges for pragmatic research. Data from this study provide a starting point to developing solutions to these surprisingly complex issues.
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Nayak RK, Wendler D. Is it important to disclose how treatments are selected in clinical research and clinical care? AJOB Empir Bioeth 2017; 8:170-177. [PMID: 28949900 DOI: 10.1080/23294515.2017.1314392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Current practice and policies maintain that it is very important to disclose to potential research subjects that their treatment will be selected by randomization. In contrast, it typically is not considered important to disclose to patients how doctors select their treatment. Unfortunately, when the available treatment options are similar to one another, this approach has the potential to inadvertently undermine both clinical research and clinical care. Hence, it is important to assess whether, in the context of similar treatment options, individuals support current practice of using very different disclosure practices in research and care. METHODS Respondents were randomly presented with either (1) a "drug" scenario involving two medications for hypertension (called CTD and TRT) whose risk-benefit profiles are very similar, or (2) a "dose timing" scenario involving morning versus nighttime dosing of the same antihypertensive. Respondents were asked whether, in the presented scenario, they agree, using a 7-point scale (1 = strongly disagree, 4 = neutral, 7 = strongly agree), that it is important to disclose to potential research subjects that whether they receive CTD or TRT/AM or PM dosing will be determined by randomization. Respondents were also asked whether they agree, using the same 7-point scale, that it is important to disclose to patients who face the same treatment options how their doctor will decide whether they receive CTD or TRT/AM or PM dosing. RESULTS The survey was sent to 3330 online GfK KnowledgePanel members and completed by 2130 (response rate, 64.0%). Respondents indicated that it is somewhat important to disclose to potential subjects that whether they receive CTD or TRT/AM or PM dosing will be determined by randomization (mean, 5.10 [95% CI, 5.02 to 5.17]). Respondents also indicated that it is slightly more important to disclose to patients who face the same treatment options how the doctor will decide whether they receive CTD or TRT/AM or PM dosing (mean, 5.29 [95% CI, 5.22 to 5.36]; p < .001). In addition, 66.4% indicated that, in the setting of similar options, it is equally important to disclose how treatment is selected in research and care, 20.5% indicated it is more important to disclose this information in clinical care, and 13.1% indicated it is more important to disclose it in research. CONCLUSION When the available options are similar to each other, individuals do not support current practice and policies that maintain that disclosure of how treatments are selected is very important in clinical research but not important in clinical care. Future research will be needed to evaluate the feasibility of developing disclosure practices and policies for this context that are consistent with individuals' views.
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Dal-Ré R, Carcas AJ, Carné X, Wendler D. Patients' beliefs regarding informed consent for low-risk pragmatic trials. BMC Med Res Methodol 2017; 17:145. [PMID: 28923007 PMCID: PMC5604493 DOI: 10.1186/s12874-017-0424-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 09/10/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The requirement to obtain written informed consent may undermine the potential of pragmatic randomized clinical trials (pRCTs) to improve evidence-based care. This requirement could compromise trials statistical power or even force it to close them down prematurely. However, recent data from the U.S. and Spain suggest that a majority of the public endorses written consent for low-risk pRCTs. The present manuscript assesses whether this view is shared by patients. METHODS This was a cross-sectional, probability-based survey, with a 2 × 2 factorial design, assessing support for written informed consent versus verbal consent or general notification for two low-risk pRCTs in hypertension, one comparing 2 drugs with similar risk/benefit profiles and the other comparing the same drug being taken in the morning or at night. This web-based survey was conducted in May 2016. Two-thousand and eight adults who were representative of the Spanish population participated in the survey (response rate: 61%). Of these 2008 respondents, 338 indicated that they had been diagnosed with hypertension and were being treated with prescription medicines for this condition at the time of responding to the survey. The primary outcome measures were respondents' personal preference and recommendation to a research ethics committee regarding the use of written informed consent versus verbal consent or general notification. RESULTS Overall, 74% of the 338 patient respondents endorsed written consent. In both scenarios, general notification received significantly more support (30.6%-44.7%) than verbal consent (13.3%-17.6%). 43% of respondents preferred and/or recommended general notification rather than written consent. CONCLUSIONS As in the survey of the general public, more patients endorsed written consent than the alternative option. However, two factors suggest that a different approach to written consent should be investigated for low-risk pRCTs: a) a substantial minority of respondents supported general notification, b) data from the US have shown that most patients who prefer written consent are willing to forego it if obtaining written consent makes the trial too difficult to be conducted; and c) 2016 CIOMS guidelines endorse waivers of consent when the trial fulfills specific conditions. Surveys in other EU countries are needed to assess what patients believe towards pRCTs. If similar results to that reported in this study are found, it is foreseeable that with educational efforts, general notification could be an acceptable and widespread approach to the conduct of low-risk pRCTs.
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Affiliation(s)
- Rafael Dal-Ré
- Clinical Research, BUC (Biosciences UAM+CSIC) Program, International Campus of Excellence, Universidad Autónoma de Madrid, Ciudad Universitaria de Cantoblanco, Einstein 3, 28049, Madrid, Spain.
- Chair on Bioethics "Grifols Foundation", University of Vic - Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, E-08500, Vic, Barcelona, Spain.
- Epidemiology Unit, Health Research Institute-Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, Avda. Reyes Católicos 2, E-28040, Madrid, Spain.
| | - Antonio J Carcas
- Clinical Pharmacology Department, La Paz University Hospital, IdiPaz, School of Medicine, Universidad Autónoma de Madrid, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Xavier Carné
- Chair on Bioethics "Grifols Foundation", University of Vic - Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, E-08500, Vic, Barcelona, Spain
- Clinical Pharmacology Department, Clínic Hospital, August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Clinical Fundamentals Department, Universidad de Barcelona, Carrer de Villarroel 170, 08036, Barcelona, Spain
| | - David Wendler
- Section on Research Ethics, Department of Bioethics, NIH Clinical Center, 10 Center Dr, Bethesda, MD, 20814, USA
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Carpenter D, Gonzalez D, Retsch-Bogart G, Sleath B, Wilfond B. Methodological and Ethical Issues in Pediatric Medication Safety Research. Pediatrics 2017; 140:e20170195. [PMID: 28778857 PMCID: PMC5574727 DOI: 10.1542/peds.2017-0195] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 12/26/2022] Open
Abstract
In May 2016, the Eshelman School of Pharmacy at The University of North Carolina at Chapel Hill convened the PharmSci conference to address the topic of "methodological and ethical issues in pediatric medication safety research." A multidisciplinary group of experts representing a diverse array of perspectives, including those of the US Food and Drug Administration, children's hospitals, and academia, identified important considerations for pediatric medication safety research and opportunities to advance the field. This executive summary describes current challenges that clinicians and researchers encounter related to pediatric medication safety research and identifies innovative and ethically sound methodologies to address these challenges to improve children's health. This article addresses 5 areas: (1) pediatric drug development and drug trials; (2) conducting comparative effectiveness research in pediatric populations; (3) child and parent engagement on study teams; (4) improving communication with children and parents; and (5) assessing child-reported outcomes and adverse drug events.
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Affiliation(s)
| | | | - George Retsch-Bogart
- Department of Pediatrics, School of Medicine
- Clinical and Translational Research Center of the North Carolina Translational and Clinical Sciences Institute, and
- Cystic Fibrosis Therapeutics Development Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and
| | | | - Benjamin Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, University of Washington, Seattle, Washington
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Dickert NW, Hendershot KA, Speight CD, Fehr AE. Patients' views of consent in clinical trials for acute myocardial infarction: impact of trial design. JOURNAL OF MEDICAL ETHICS 2017; 43:524-529. [PMID: 28039285 DOI: 10.1136/medethics-2016-103866] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/21/2016] [Accepted: 12/07/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Seeking prospective informed consent is difficult in clinical trials for emergent conditions such as acute myocardial infarction (AMI). Prior data suggest that enrolment decisions of patients are often poorly informed in AMI trials but that patients prefer to be asked permission before enrolment. It is unknown whether this is true across trial designs or in comparative effectiveness research (CER) with approved treatments. METHODS Structured interviews were conducted with 30 patients with AMI. Participants considered three scenarios: (1) a CER trial of approved antiplatelet drugs; (2) a placebo-controlled trial of a novel drug to reduce myocardial injury and (3) a CER trial of an intra-aortic balloon pump versus medication. Participants were asked their desired involvement in enrolment decisions and willingness to participate. Descriptive analysis was performed of Likert scale data, and qualitative descriptive analysis was performed of textual data. RESULTS Across scenarios, most participants (73%-80%) preferred to be asked permission prior to trial enrolment. Reasons for involvement included wanting to be the decision maker and a desire for transparency. Willingness to enrol was affected by trial type. Fewer participants stated they would likely enrol in a CER procedural trial than in a CER trial of approved medications (p=0.012). CONCLUSIONS These findings suggest that patients prefer prospective involvement in enrolment decisions to enrolment without consent across trial types. However, their desire to participate was affected by trial type. There is a need to develop and evaluate context-sensitive approaches to consent in AMI trials that account for both the acuity of the situation and trial characteristics.
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Affiliation(s)
- Neal W Dickert
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Emory Center for Ethics, Atlanta, Georgia, USA
| | | | - Candace D Speight
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alexandra E Fehr
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Partners in Health, Butaro, Rwanda
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Kraft SA, Porter KM, Korngiebel DM, James C, Constantine M, Kelley M, Capron AM, Diekema D, Lee SSJ, Cho MK, Magnus D, Wilfond BS. Research on Medical Practices: Why Patients Consider Participating and the Investigational Misconception. IRB 2017; 39:10-16. [PMID: 30387977 PMCID: PMC7374557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Understanding how patients decide whether to enroll in research can help improve educational materials, protocols, and recruitment rates. However, little is known about patients' willingness to participate in research on medical practices (ROMP), or studies comparing interventions within usual care. We assessed willingness to consider participating in ROMP by surveying 1095 adults in the United States, of whom 834 answered at least one open-ended question about their reasons for being willing or unwilling to consider participating in two scenarios involving ROMP. Most respondents were willing to consider participating in the research scenarios. The most commonly cited reasons for being willing to consider participating included benefit to others and oneself; the top reasons for being unwilling to consider participating included belief that the research was unsafe and an unfavorable view of experimentation. Responses also revealed misconceptions about ROMP among both those who were willing and unwilling to consider participating. Because these misconceptions may present an obstacle to recruiting participants in ROMP, there may be a need for educational initiatives to clarify the nature of these types of studies.
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Affiliation(s)
| | | | | | | | | | | | | | - Douglas Diekema
- University of Washington
- Seattle Children's Research Institute
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Can Appealing to Patient Altruism Reduce Overuse of Health Care Services? An Experimental Survey. J Gen Intern Med 2017; 32:732-738. [PMID: 28155043 PMCID: PMC5481226 DOI: 10.1007/s11606-017-4002-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 12/05/2016] [Accepted: 01/18/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND A challenge to reducing overuse of health services is communicating recommendations against unnecessary health services to patients. The predominant approach has been to highlight the limited benefit and potential harm of such services for that patient, but the prudent use of health resources can also benefit others. Whether appealing to patient altruism can reduce overuse is unknown. OBJECTIVE To determine whether altruistic appeals reduce hypothetical requests for overused services and affect physician ratings. DESIGN Experimental survey using hypothetical vignettes describing three overused health services (antibiotics for acute sinusitis, imaging for acute low back pain, and annual exams for healthy adults). PARTICIPANTS U.S. adults recruited from Research Now, an online panel of individuals compensated for performing academic and marketing research surveys. INTERVENTIONS In the control version of the vignettes, the physician's rationale for recommending against the service was the minimal benefit and potential for harm. In the altruism version, the rationale additionally included potential benefit to others by forgoing that service. MAIN MEASURES Differences in requests for overused services and physician ratings between participants randomized to the control and altruism versions of the vignettes. KEY RESULTS A total of 1001 participants were included in the final analyses. There were no significant differences in requests for overused services for any of the clinical scenarios (P values ranged from 0.183 to 0.547). Physician ratings were lower in the altruism version for the acute sinusitis (6.68 vs. 7.03, P = 0.012) and back pain scenarios (6.14 vs. 6.83, P < 0.001), and marginally lower for the healthy adult scenario (5.27 vs. 5.57, P = 0.084). CONCLUSIONS In this experimental survey, altruistic appeals delivered by physicians did not reduce requests for overused services, and resulted in more negative physician ratings. Further studies are warranted to determine whether alternative methods of appealing to patient altruism can reduce overuse.
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Dal-Ré R, Carcas AJ, Carné X, Wendler D. Public preferences on written informed consent for low-risk pragmatic clinical trials in Spain. Br J Clin Pharmacol 2017; 83:1921-1931. [PMID: 28419518 PMCID: PMC5582372 DOI: 10.1111/bcp.13305] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 04/06/2017] [Accepted: 04/08/2017] [Indexed: 01/29/2023] Open
Abstract
Aims Pragmatic randomized clinical trials (pRCTs) collect data that have the potential to improve medical care significantly. However, these trials may be undermined by the requirement to obtain written informed consent, which can decrease accrual and increase selection bias. Recent data suggest that the majority of the US public endorses written consent for low‐risk pRCTs. The present study was designed to assess whether this view is specific to the US. Methods The study took the form of a cross‐sectional, probability‐based survey, with a 2 × 2 factorial design, assessing support for written informed consent vs. verbal consent or general notification for two low‐risk pRCTs in hypertension, one comparing two drugs with similar risk/benefit profiles and the other comparing the same drug being taken in the morning or at night. The primary outcome measures were respondents' personal preference and hypothetical recommendation to a research ethics committee regarding the use of written informed consent vs. the alternatives. Results A total of 2008 adults sampled from a probability‐based online panel responded to the web‐based survey conducted in May 2016 (response rate: 61%). Overall, 77% of respondents endorsed written consent. In both scenarios, the alternative of general notification received significantly more support (28.7–37.1%) than the alternative of verbal consent (12.7–14.0%) (P = 0.001). Forty per cent of respondents preferred and/or recommended general notification rather than written consent. Conclusions The results suggested that, rather than attempting to waive written consent, current pRCTs should focus on developing ways to implement written consent that provide sufficient information without undermining recruitment or increasing selection bias. The finding that around 40% of respondents endorsed general notification over written consent raises the possibility that, with educational efforts, the majority of Spaniards might accept general notification for low‐risk pRCTs.
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Affiliation(s)
- Rafael Dal-Ré
- Clinical Research, BUC (Biosciences UAM+CSIC) Program, International Campus of Excellence, Universidad Autónoma de Madrid, Ciudad Universitaria de Cantoblanco, Einstein 3, 28049, Madrid, Spain.,Chair on Bioethics 'Grifols Foundation', University of Vic-Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, 08500, Vic, Barcelona, Spain
| | - Antonio J Carcas
- Clinical Pharmacology Department, La Paz University Hospital, IdiPaz, School of Medicine, Universidad Autónoma de Madrid, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Xavier Carné
- Chair on Bioethics 'Grifols Foundation', University of Vic-Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, 08500, Vic, Barcelona, Spain.,Clinical Pharmacology Department, Clínic Hospital, August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Clinical Fundamentals Department, Universidad de Barcelona, Carrer de Villarroel 170, 08036, Barcelona, Spain.,Chair on Bioethics 'Grifols Foundation', University of Vic-Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, E-08500, Vic, Barcelona, Spain
| | - David Wendler
- Section on Research Ethics, Department of Bioethics, NIH Clinical Center, 10 Center Drive, Bethesda, MD, 20814,, USA
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Targeted Consent for Research on Standard of Care Interventions in the Emergency Setting. Crit Care Med 2017; 45:e105-e110. [PMID: 27509386 DOI: 10.1097/ccm.0000000000002023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES There has been significant debate over what consent process, if any, should be used for clinical trials that compare two or more interventions within the standard of care. Some claim that all clinical trials should obtain in-depth research consent because they use subjects to obtain data for the benefit of future patients. Others argue that clinical trials that are limited to interventions within the standard of care do not need to obtain research consent at all. Settling this debate is especially challenging in the emergency setting. The potential for significant morbidity and mortality provides a strong reason to obtain research consent for standard-of-care trials in the emergency setting. Yet, the emergency setting also introduces significant barriers to traditional in-depth research consent. The present article considers to what extent a targeted consent process can resolve these tensions. DATA SYNTHESIS We first identified the ethical goals that are promoted by obtaining consent for standard-of-care research and the barriers to obtaining consent that arise in the emergency setting. We then evaluated whether, despite the barriers, it is possible to develop a targeted consent process that promotes the goals for consent in the context of standard-of-care trials. CONCLUSIONS Targeted consent offers an ethically appropriate way to obtain consent for many standard-of-care trials in the emergency setting. For studies subject to U.S. regulations, and those subject to other regulations that include similar consent requirements, targeted consent's verbal disclosure and written form provide a way to satisfy research regulations without blocking valuable studies. For trials that qualify for a waiver of the consent requirements, targeted consent's verbal disclosure is preferable to waiving consent, provided a slight delay is consistent with appropriate care, and there is a capacitated patient or surrogate available.
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Kim KK, Sankar P, Wilson MD, Haynes SC. Factors affecting willingness to share electronic health data among California consumers. BMC Med Ethics 2017; 18:25. [PMID: 28376801 PMCID: PMC5381052 DOI: 10.1186/s12910-017-0185-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 03/24/2017] [Indexed: 11/10/2022] Open
Abstract
Background Robust technology infrastructure is needed to enable learning health care systems to improve quality, access, and cost. Such infrastructure relies on the trust and confidence of individuals to share their health data for healthcare and research. Few studies have addressed consumers’ views on electronic data sharing and fewer still have explored the dual purposes of healthcare and research together. The objective of the study is to explore factors that affect consumers’ willingness to share electronic health information for healthcare and research. Methods This study involved a random-digit dial telephone survey of 800 adult Californians conducted in English and Spanish. Logistic regression was performed using backward selection to test for significant (p-value ≤ 0.05) associations of each explanatory variable with the outcome variable. Results The odds of consent for electronic data sharing for healthcare decreased as Likert scale ratings for EHR impact on privacy worsened, odds ratio (OR) = 0.74, 95% CI [0.60, 0.90]; security, OR = 0.80, 95% CI [0.66, 0.98]; and quality, OR = 0.59, 95% CI [0.46–0.75]. The odds of consent for sharing for research was greater for those who think EHR will improve research quality, OR = 11.26, 95% CI [4.13, 30.73]; those who value research benefit over privacy OR = 2.72, 95% CI [1.55, 4.78]; and those who value control over research benefit OR = 0.49, 95% CI [0.26, 0.94]. Conclusions Consumers’ choices about electronically sharing health information are affected by their attitudes toward EHRs as well as beliefs about research benefit and individual control. Design of person-centered interventions utilizing electronically collected health information, and policies regarding data sharing should address these values of importance to people. Understanding of these perspectives is critical for leveraging health data to support learning health care systems.
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Affiliation(s)
- Katherine K Kim
- University of California Davis, Betty Irene Moore School of Nursing, 2450 48th Street, Suite 2600, Sacramento, CA, 95817, USA.
| | - Pamela Sankar
- Department of Medical Ethics and Health Policy, University of Pennsylvania, 423 Guardian Drive, Blockley, 14, Philadelphia, PA19104-4884, USA
| | - Machelle D Wilson
- Department of Public Health Sciences, Division of Biostatistics, Clinical and Translational Science Center, University of California Davis, 2921 Stockton Blvd, suite 1400, Sacramento, CA, 95817, USA
| | - Sarah C Haynes
- University of California Davis, Betty Irene Moore School of Nursing, 2450 48th Street, Suite 2600, Sacramento, CA, 95817, USA
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