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Chongwe G, Ali J, Kaye DK, Michelo C, Kass N. Ethics of Adaptive Designs for Randomized Controlled Trials. Ethics Hum Res 2023; 45:2-14. [PMID: 37777976 PMCID: PMC10739783 DOI: 10.1002/eahr.500178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Over recent decades, adaptive trial designs have been used more and more often for clinical trials, including randomized controlled trials (RCTs). This rise in the use of adaptive RCTs has been accompanied by debates about whether such trials offer ethical and methodological advantages over traditional, fixed RCTs. This study examined how experts on clinical trial methods and ethics believe that adaptive RCTs, compared to fixed ones, affect the ethical character of clinical research. We conducted in-depth interviews with 17 researchers from bioethics, epidemiology, biostatistics, and/or medical backgrounds. While about half believed that adaptive trials are more complex and may thus threaten autonomy, these respondents also expressed that this challenge is not insurmountable. Most respondents expressed that efficiency and potential for participant benefit were the main justifications for adaptive trials. There was tension about whether adaptive randomization in response to increasing information disrupts clinical equipoise, with some respondents insisting that uncertainty still exists and therefore clinical equipoise is not disrupted. These findings suggest that further discussion is needed to increase the awareness and utility of these study designs.
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Affiliation(s)
- Gershom Chongwe
- School of Public Health, University of Zambia, Department
of Epidemiology and Biostatistics, Box 50110, Lusaka, Zambia
- Johns Hopkins University, Berman Institute of Bioethics,
1809 Ashland Avenue, Baltimore, MD, 21205, USA
- Tropical Diseases Research Centre, Box 71769, Ndola,
Zambia
| | - Joseph Ali
- Johns Hopkins University, Berman Institute of Bioethics,
1809 Ashland Avenue, Baltimore, MD, 21205, USA
| | - Daniel K. Kaye
- College of Health Sciences, Department of Obstetrics and
Gynaecology, Makerere University
| | - Charles Michelo
- School of Public Health, University of Zambia, Department
of Epidemiology and Biostatistics, Box 50110, Lusaka, Zambia
| | - Nancy Kass
- Johns Hopkins University, Berman Institute of Bioethics,
1809 Ashland Avenue, Baltimore, MD, 21205, USA
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Cadegiani F, Goren A, Wambier C, McCoy J. Early COVID-19 therapy with azithromycin plus nitazoxanide, ivermectin or hydroxychloroquine in outpatient settings significantly improved COVID-19 outcomes compared to known outcomes in untreated patients. New Microbes New Infect 2021; 43:100915. [PMID: 34249367 PMCID: PMC8262389 DOI: 10.1016/j.nmni.2021.100915] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In a prospective observational study (pre-AndroCoV Trial), the use of nitazoxanide, ivermectin and hydroxychloroquine demonstrated unexpected improvements in COVID-19 outcomes when compared to untreated patients. The apparent yet likely positive results raised ethical concerns on the employment of further full placebo controlled studies in early-stage COVID-19. The present analysis aimed to elucidate, through a comparative analysis with two control groups, whether full placebo-control randomized clinical trials (RCTs) on early-stage COVID-19 are still ethically acceptable. The Active group (AG) consisted of patients enrolled in the Pre-AndroCoV-Trial (n = 585). Control Group 1 (CG1) consisted of a retrospectively obtained group of untreated patients of the same population (n = 137), and Control Group 2 (CG2) resulted from a precise prediction of clinical outcomes based on a thorough and structured review of indexed articles and official statements. Patients were matched for sex, age, comorbidities and disease severity at baseline. Compared to CG1 and CG2, AG showed reduction of 31.5-36.5% in viral shedding (p < 0.0001), 70-85% in disease duration (p < 0.0001), and 100% in respiratory complications, hospitalization, mechanical ventilation, deaths and post-COVID manifestations (p < 0.0001 for all). For every 1000 confirmed cases for COVID-19, at least 70 hospitalizations, 50 mechanical ventilations and five deaths were prevented. Benefits from the combination of early COVID-19 detection and early pharmacological approaches were consistent and overwhelming when compared to untreated groups, which, together with the well-established safety profile of the drug combinations tested in the Pre-AndroCoV Trial, precluded our study from continuing employing full placebo in early COVID-19.
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Affiliation(s)
- F.A. Cadegiani
- Corpometria Institute, Brasília, DF, Brazil
- Applied Biology, Inc., Irvine, CA, USA
| | - A. Goren
- Applied Biology, Inc., Irvine, CA, USA
| | - C.G. Wambier
- Department of Dermatology, The Alpert Medical School of Brown University, RI, USA
| | - J. McCoy
- Applied Biology, Inc., Irvine, CA, USA
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Affiliation(s)
- Rafael Dal-Ré
- Epidemiology Unit, Health Research Institute-Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
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Barnbaum DR. Randomization Among: The Other Randomization. Ethics Hum Res 2019; 41:35-40. [PMID: 31541539 DOI: 10.1002/eahr.500031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A valid informed consent process for a randomized controlled trial requires the disclosure to potential participants that they will be randomized to receive the study intervention or a control intervention. This is a case of randomization within a trial, a type of randomization that has received significant attention in research ethics. When institutions recruit large numbers of research participants for multisite clinical trials, a different, hidden form of randomization may occur: randomization among clinical trials. If it is essential to disclose to potential participants randomization within a clinical trial, then it may be the case that randomization among clinical trials recruiting individuals from the same cohort of eligible participants should also be disclosed. This article examines how randomization among clinical trials might take place and the ethical issues such randomization raises about informed consent to research participation.
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Selker HP, Daudelin DH, Ruthazer R, Kwong M, Lorenzana RC, Hannon DJ, Wong JB, Kent DM, Terrin N, Moreno-Koehler AD, McAlindon TE. The use of patient-specific equipoise to support shared decision-making for clinical care and enrollment into clinical trials. J Clin Transl Sci 2019; 3:27-36. [PMID: 31404154 DOI: 10.1017/cts.2019.380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: To enhance enrollment into randomized clinical trials (RCTs), we proposed electronic health record-based clinical decision support for patient–clinician shared decision-making about care and RCT enrollment, based on “mathematical equipoise.” Objectives: As an example, we created the Knee Osteoarthritis Mathematical Equipoise Tool (KOMET) to determine the presence of patient-specific equipoise between treatments for the choice between total knee replacement (TKR) and nonsurgical treatment of advanced knee osteoarthritis. Methods: With input from patients and clinicians about important pain and physical function treatment outcomes, we created a database from non-RCT sources of knee osteoarthritis outcomes. We then developed multivariable linear regression models that predict 1-year individual-patient knee pain and physical function outcomes for TKR and for nonsurgical treatment. These predictions allowed detecting mathematical equipoise between these two options for patients eligible for TKR. Decision support software was developed to graphically illustrate, for a given patient, the degree of overlap of pain and functional outcomes between the treatments and was pilot tested for usability, responsiveness, and as support for shared decision-making. Results: The KOMET predictive regression model for knee pain had four patient-specific variables, and an r2 value of 0.32, and the model for physical functioning included six patient-specific variables, and an r2 of 0.34. These models were incorporated into prototype KOMET decision support software and pilot tested in clinics, and were generally well received. Conclusions: Use of predictive models and mathematical equipoise may help discern patient-specific equipoise to support shared decision-making for selecting between alternative treatments and considering enrollment into an RCT.
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Piasecki J, Dranseika V. Research versus practice: The dilemmas of research ethics in the era of learning health-care systems. Bioethics 2019; 33:617-624. [PMID: 30887541 DOI: 10.1111/bioe.12571] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 10/23/2018] [Accepted: 12/22/2018] [Indexed: 06/09/2023]
Abstract
In this article we attempt to answer the question of how the ethical and conceptual framework (ECF) for a learning health-care system (LHS) affects some of the main controversies in research ethics by addressing five key problems of research ethics: (a) What is the difference between practice and research? (b) What is the relationship between research ethics and clinical ethics? (c) What is the ethical relevance of the principle of clinical equipoise? (d) Does participation in research require a higher standard of informed consent than the practice of medicine? and (e) What ethical principle should take precedence in medicine? These questions allow us to construct two opposite idealized positions on the distinction between research and practice: the integration model and the segregation model of research and practice. We then compare the ECF for an LHS with these two idealized positions. We argue that the ECF for a LHS does not, in fact, solve these problems, but that it is a third, separate position in the relationship between research ethics and clinical ethics. Moreover, we suggest that the ECF for a LHS raises new ethical problems that require additional ethical analysis and justification. Our article contributes to the discussion on the relationship between research ethics and clinical ethics, revealing that although a learning health-care system may significantly change the landscape of health care, some ethical dilemmas still require resolving on both theoretical and policy-making levels.
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Affiliation(s)
- Jan Piasecki
- Department of Philosophy and Bioethics, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Vilius Dranseika
- Department of Philosophy and Bioethics, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
- Institute of Philosophy, Vilnius University, Lithuania
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Hamilton AER, Young CJ. Surveys still teach vital non-technical lessons in General Surgery. ANZ J Surg 2018; 89:159-164. [PMID: 30485674 DOI: 10.1111/ans.14932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/23/2018] [Accepted: 09/29/2018] [Indexed: 11/27/2022]
Abstract
In general surgery, observational studies are disregarded and often seen as non-noteworthy research. We intend to defend the use of surveys in general surgery and colorectal surgery. This review highlights the historical importance and contemporary utility of surveys internationally and in our region, thus reminding Australasian surgeons and clinicians in numerous disciplines of the usefulness of this research tool. Well-constructed surveys often successfully capture qualitative data otherwise impossible to collect through randomized controlled trial. The results of these surveys may advise national policies and medical registration agencies thus having a direct influence on individuals and their public health. Samples from contemporary survey-based research publications from international and Australasian authors are used to illustrate some of the vital non-technical lessons learned in recent times.
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Affiliation(s)
- Auerilius E R Hamilton
- Colorectal Surgery Unit, Royal Prince Alfred Hospital, Institute of Academic Surgery, Sydney, New South Wales, Australia
| | - Christopher J Young
- Colorectal Surgery Unit, Royal Prince Alfred Hospital, Institute of Academic Surgery, Sydney, New South Wales, Australia.,Discipline of Surgery, The University of Sydney, Sydney, New South Wales, Australia
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Webster F, Weijer C, Todd L, Grimshaw JM, Marshall AP, Cook D, MacLennan G, Cuthbertson BH, Francis JJ. The ethics of future trials: qualitative analysis of physicians' decision making. Trials 2016; 17:12. [PMID: 26739307 PMCID: PMC4704430 DOI: 10.1186/s13063-015-1137-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 12/18/2015] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The decision to conduct a randomized controlled trial (RCT) in a field raises ethical as well as scientific issues. From the clinical equipoise literature, future trials are justifiable if there is "honest, professional disagreement in the community of expert practitioners as to the preferred treatment". Empirical data are sparse about how clinicians apply the principles of equipoise to the justification of future RCTs. For example, selective decontamination of the digestive tract (SDD) is not widely used in critical care practice despite the strength of the evidence base and therefore provides a unique opportunity to learn how clinicians think about the ethics of further RCTs in critical care. METHODS In an international interview study of views of healthcare professionals about SDD, we undertook a secondary analysis of qualitative data collected using a Theoretical Domains Framework of clinical behaviour. We adopted a general descriptive approach to explore how physicians determined whether another RCT of SDD is ethical. Following a constant comparison approach, three investigators reviewed 54 purposively chosen transcripts from three international regions. We interpreted the data using thematic analysis. RESULTS We grouped participants' responses into four inter-related themes: 1) cultural norms about evidence and practice within healthcare; 2) personal views about what evidence is current or applicable; 3) the interpersonal and relational nature of professional decision making locally; and 4) an a priori commitment to future trials. The analysis also identified several unresolved tensions regarding when a future RCT should be pursued. These tensions focused on a clash between potential benefits to current individual patients and potential future harms to patients more broadly. CONCLUSIONS Our study suggests that ethical decision making about future RCTs in the field of SDD does not rely strongly on appeals to evidence, even when the quality of the evidence is reasonably high. Rather, "extra-evidential" reasons, including social, professional, and relational factors, seem to influence opinions regarding the ethics of future trials. Further work is required to see if these conclusions are applicable to other clinical topics and settings.
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Affiliation(s)
- Fiona Webster
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, Ontario, M5G 1V7, Canada.
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, 1151 Richmond Street, London, Ontario, N6A 5B8, Canada.
| | - Laura Todd
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, Ontario, M5G 1V7, Canada.
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
- Department of Medicine, University of Ottawa, Ottawa Hospital - General Campus, Centre for Practice-Changing Research, 501 Smyth Road, Room 1286, Ottawa, Ontario, K1H 8L6, Canada.
| | - Andrea P Marshall
- Menzies Health Institute Queensland, Griffith University and Gold Coast University Hospital, D.5 090 1 Hospital Blvd, Southport, QLD 4215, Australia.
| | - Deborah Cook
- Departments of Medicine, Clinical Epidemiology & Biostatistics, McMaster University, Faculty of Health Sciences, 1280 Main Street West, Rm. 2C11, Hamilton, Ontario, L8S 4K1, Canada.
| | - Graeme MacLennan
- Health Services Research Unit, Health Sciences Building, Foresterhill, University of Aberdeen, Aberdeen, AB25 2ZD, UK.
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.
- Department of Anesthesia, University of Toronto, Toronto, Canada.
| | - Jill J Francis
- School of Health Sciences, City University London, Northampton Square, London, EC1V OHB, UK.
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Ramakrishna H, Ghadimi K, Augoustides JGT. Incidental moderate mitral regurgitation in patients undergoing coronary artery bypass grafting: update on guidelines and key randomized trials. J Cardiothorac Vasc Anesth 2014; 28:189-193. [PMID: 24440010 DOI: 10.1053/j.jvca.2013.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Indexed: 11/11/2022]
Abstract
Incidental moderate mitral regurgitation (MR) in patients presenting for coronary artery bypass grafting (CABG) is not only common but also probably adversely affects clinical outcome. The echocardiographic evaluation of incidental MR must be comprehensive and integrated, as it remains a cornerstone in management decisions. Current guidelines support surgical mitral intervention in this setting as a reasonable option, reflecting clinical equipoise towards moderate MR in the setting of planned CABG. There are currently 2 major randomized trials in progress that will test whether surgical correction of moderate MR combined with CABG improves major clinical outcomes as compared to CABG alone. These landmark trials will be completed in the near future. In the interim, significant progress in the fields of cardiac resynchronization therapy, transcatheter mitral valve intervention, and minimally invasive mitral valve surgery promise to affect the management alternatives for moderate MR in patients undergoing CABG regardless of operative risk. It is likely that in the coming decade there will be less tolerance for incidental moderate MR given its already known outcome effects and the multimodal interventions that continue to mature with better safety profiles.
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Affiliation(s)
| | - Kamrouz Ghadimi
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Abstract
While ethical behavior has always been part of cardiac surgical practice, ethical deliberation has only recently become an important component of cardiac surgical practice. Issues such as informed consent, conflict of interest and professional self-regulation, among many others, have increasingly attracted the attention of cardiac surgeons. This article covers several broad topics of interest to cardiac surgeons and cardiologists and discusses several other topics more briefly. There is much uncertainty regarding what the future holds for cardiac surgical practice, research and culture and we also discuss the background of ethical issues to serve as a platform for envisioning what is to come.
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Affiliation(s)
- Minoo N. Kavarana
- Surgery Division of Pediatric Cardiothoracic Surgery 96 Jonathan Lucas Street, CSB 424, MSC 613 Charleston, SC 29425-6130 843 792 3361 (office), 843 792 8286 (Fax)
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Abstract
N-of-1 or single subject clinical trials consider an individual patient as the sole unit of observation in a study investigating the efficacy or side-effect profiles of different interventions. The ultimate goal of an n-of-1 trial is to determine the optimal or best intervention for an individual patient using objective data-driven criteria. Such trials can leverage study design and statistical techniques associated with standard population-based clinical trials, including randomization, washout and crossover periods, as well as placebo controls. Despite their obvious appeal and wide use in educational settings, n-of-1 trials have been used sparingly in medical and general clinical settings. We briefly review the history, motivation and design of n-of-1 trials and emphasize the great utility of modern wireless medical monitoring devices in their execution. We ultimately argue that n-of-1 trials demand serious attention among the health research and clinical care communities given the contemporary focus on individualized medicine.
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Affiliation(s)
- Elizabeth O Lillie
- Scripps Health, La Jolla, CA 92037, USA
- The Scripps Translational Science Institute, La Jolla, CA 92037, USA
| | - Bradley Patay
- Scripps Health, La Jolla, CA 92037, USA
- The Scripps Translational Science Institute, La Jolla, CA 92037, USA
| | - Joel Diamant
- Scripps Health, La Jolla, CA 92037, USA
- The Scripps Translational Science Institute, La Jolla, CA 92037, USA
| | - Brian Issell
- Scripps Health, La Jolla, CA 92037, USA
- The Scripps Translational Science Institute, La Jolla, CA 92037, USA
| | - Eric J Topol
- Scripps Health, La Jolla, CA 92037, USA
- The Scripps Translational Science Institute, La Jolla, CA 92037, USA
- The Scripps Research Institute, La Jolla, CA 92047, USA
- The West Wireless Health Institute, La Jolla, CA 92037, USA
| | - Nicholas J Schork
- Scripps Health, La Jolla, CA 92037, USA
- The Scripps Translational Science Institute, La Jolla, CA 92037, USA
- The Scripps Research Institute, La Jolla, CA 92047, USA
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