Meeting unique requirements: Community consultation and public disclosure for research in emergency setting using exception from informed consent

Measuring the efficacy of community consultation in a pediatric exception from informed consent trial

BACKGROUND

Community consultation activities are required by the Food and Drug Administration prior to conducting research using exception from informed consent (EFIC) for emergency research and aim to provide additional participant protections. However, it is difficult for institutional review boards (IRBs) to assess the efficacy of such activities. In this study, our primary aim was to evaluate the efficacy of the PediDOSE trial's consultation activities by answering key questions about whether consultation efforts reached a relevant community and if the perspectives of the consulted community coincided with those of parents actually enrolled in the study.

METHODS

Qualitative findings of semistructured interview data collected during community consultation efforts were compared with interview responses from parents of children enrolled in the PediDOSE trial to identify common themes.

RESULTS

Most themes were identified in both groups, but additional themes emerged with parents of enrolled participants that may be important for future study teams and IRBs to consider. Even with an overrepresentation of White and non-Hispanic/Latino participants in the community consultations compared to those who were enrolled in the EFIC study there was common overlap of themes.

CONCLUSIONS

Parent interviews added to our understanding beyond the themes identified in the consultation interviews. The theme of therapeutic misconception was not found in the consultation interviews, possibly due to the child's emergency medical care being theoretical. With modest accommodations, collection of additional demographic and follow-up interview data can successfully assess key elements of community consultation efficacy for EFIC trials.

Application of digital engagement tools for exception from informed consent community consultation and public disclosure in the pediatric prehospital airway resuscitation trial

Background

Emergency care trials may require compliance with federal Exception from Informed Consent (EFIC) regulations, including community consultation (CC) and public disclosure (PD). The reach of traditional CC and PD modalities is limited. We describe the application of novel digital engagement tools to enrich CC and PD in a pediatric emergency care trial.

Methods

In support of EFIC CC and PD efforts for the Pediatric Prehospital Airway Resuscitation Trial (Pedi-PART), a multicenter trial of paramedic airway management in critically ill children, we deployed two digital engagement tools: 1) social media advertisements, and 2) marketing research panels. We disseminated social media advertisements (Facebook and Instagram) describing the study to targeted users in 10 communities. We determined social media advertisement impressions and engagements (shares, reactions, saves, comments, likes and clicks). We also disseminated community surveys using a marketing research panel (Qualtrics Marketing Research Services), determining the number of completed surveys, time to achieve 200 surveys, demographics of survey respondents and percentage with supportive responses.

Results

There were 23.3 million social media advertisement impressions (range 1.8-2.7 million per community) reaching 3.4 million unique users (range 239,494-439,360 per community) and resulting in 13,873 engagements (range 828-1,656 per community). Distribution of the community survey through the marketing research panel resulted in 6,771 completed surveys (range 531-914 per community). Across communities, time to 200 completed surveys ranged from 5-28 days. Survey respondents were 61.9% female, 27.0% minority race and 40.8% household income <$50,000. Most survey respondents (90.7%) supported the trial.

Conclusions

Digital engagement tools efficiently reached a large and diverse population and yielded key community feedback to inform research trial deployment. Digital engagement tools offer valuable techniques to enrich EFIC CC and PD efforts.

Personal Public Disclosure: A New Paradigm for Meeting Regulatory Requirements Under Exception From Informed Consent

OBJECTIVES

To describe a novel approach to the requirement for public disclosure under regulations for Exception From Informed Consent (EFIC) in an inpatient clinical trial.

DESIGN

Single-arm intervention study within a clinical trial.

SETTING

Medical and medical/surgical PICUs at an academic children's hospital.

PARTICIPANTS

Families of children and young adults younger than 26 years old receiving care in a PICU.

INTERVENTIONS

As part of a multipronged approach to meeting requirements for public disclosure for EFIC, we developed and implemented a process termed "personal public disclosure," in which a member of the study team notifies all potentially eligible patients/families in-person or by phone about the trial as soon as possible upon PICU admission. Patients/families may choose to opt out of future participation in the trial.

MEASUREMENTS AND MAIN RESULTS

Over a 16-month period, 1577 potentially eligible patients/families were successfully contacted for personal public disclosure. Of these, 473 (30%) opted out of future participation in the trial. In the same period, 64 patients developed the emergent event of interest for the primary trial. Of these, only 9 (14%) were enrolled. Upon notification of enrollment, all 9 (100%) agreed to continue in the data collection phase of the study. Of the remaining 55 missed enrollments, 38 (69%) were due to the event occurring before personal public disclosure had been completed.

CONCLUSIONS

Personal public disclosure supports patient/family autonomy within an EFIC trial; however, this approach is limited by low cost-effectiveness, feasibility and appropriateness in many circumstances.

The ethical value of consulting community members in non-emergency trials conducted with waivers of informed consent for research

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.

Emergency research without prior consent in the United States, Canada, European Union and United Kingdom: How regulatory differences affect study design and implementation in cardiac arrest trials

Aim

A major barrier to performing cardiac arrest trials is the requirement for prospective informed consent, which is often infeasible during individual medical emergencies. In an effort to improve outcomes, some governments have adopted legislation permitting research without prior consent (RWPC) in these circumstances. We aimed to outline key differences between legislation in four Western locations and explore the effects of these differences on trial design and implementation in cardiac arrest research.

Data sources

We performed a narrative review of RWPC legislation in the United States (US), Canada, the European Union (EU) and the United Kingdom (UK).

Results

The primary criteria required to perform RWPC was similar across locations: the study must involve an individual medical emergency during which neither the prospective subject nor their authorized representative can provide informed consent. The US regulations were unique in their requirements for performing Community Consultation and Public Disclosure in the communities in which the research takes place. Another major difference was the requirement for consent for ongoing participation in Canada, the EU and the UK, while only notification of enrollment and the opportunity to discontinue participation are required in the US. Additionally, only Canada and the EU explicitly state that the subject or their representative may request withdrawal of their data.

Conclusion

Regulations governing RWPC in the US, Canada, the EU and the UK have similar goals and protections for vulnerable populations during medical emergencies. Differences in the qualifying criteria and implementation procedures exist across locations and may affect study design.

Community consultation in the pediatric intensive care unit for an exception from informed consent Trial: A survey of patient caregivers

Aim

To explore perspectives of families in the pediatric intensive care unit (PICU) about an emergency interventional trial on peri-arrest bolus epinephrine for acute hypotension using Exception From Informed Consent (EFIC).

Methods

We performed face-to-face interviews with families whose children were hospitalized in the PICU. A research team member provided an educational presentation about the planned trial and administered a survey with open- and closed-ended items. Analyses included descriptive statistics for quantitative data and thematic analysis for qualitative data.

Results

Sixty-seven participants contributed to 60 survey responses (53 individuals and 7 families for whom 2 family members participated). Most participants answered favorably toward the planned trial: 55/58 (95%) reported that the trial seemed "somewhat" or "very important"; 52/57 (91%) felt the use of EFIC was "somewhat" or "completely acceptable"; and 43/58 (74%) said they would be "somewhat" or "very likely" to allow their child to participate. Five themes emerged supporting participation in the planned trial: 1) trust in the clinical team; 2) familiarity with the study intervention (epinephrine); 3) study protocol being similar to standard care; 4) informed consent during an emergency was not feasible; and 5) importance of research. Barriers to potential participation included requests for additional time to decide about participating and misconceptions about study elements, especially eligibility.

Conclusions

Families of PICU patients generally supported plans for an emergency interventional trial using EFIC. Future inpatient EFIC studies may benefit from highlighting the themes identified here in their educational materials.

A census of clinical trials conducted under the U.S. exception from informed consent rule

BACKGROUND

The exception from informed consent (EFIC) rule was adopted in 1996, permitting waiver of informed consent for certain emergency research, including trials funded by the U.S. government. The rule requires prospective consent from patients or their legally authorized representative(s) (LAR) if practicable. For those enrolled without consent, the patient or their LAR must be given an opportunity to opt out from continued participation at the earliest opportunity. We sought to census the trials conducted under the EFIC rule to facilitate research to better understand how the rule is being used.

METHODS

We conducted a multipronged search to identify all trials conducted under the EFIC rule, drawing on reviews, database searches, examination of the FDA's docket, posting an inquiry on the institutional review board forum, and email requests to lead authors of all published EFIC trials and related review articles. We describe the trials, when they were started and completed, and whether they were terminated early.

RESULTS

We identified a total of 110 trials as of the end of April 2022: 78 complete, 13 recruiting, seven registered on clinicaltrials.gov but not yet recruiting, five trials that were abandoned before enrolling any subjects, and seven trials in early planning. Nine of the 78 completed trials were pilot or feasibility trials. Of 69 completed full trials, 30 (43.5%) were terminated early. The most common reason for early termination was futility (15 trials, 25.0%) followed by poor recruitment (10 trials, 14.5%). The rate of conduct of trials has been remarkably constant since 2001, with roughly 18 trials started in each 5-year period.

CONCLUSIONS

We have compiled a census of trials conducted under the U.S. FDA's EFIC rule, the availability of which we hope will stimulate further in-depth data collection and analysis of this set of trials.

Community consultation for Exception from Informed consent (EFIC) before and during the COVID-19 pandemic

Aim

Describe community consultation and surrogate consent rates for two Exception From Informed Consent (EFIC) trials for out-of-hospital cardiac arrest (OOHCA) - before and during the COVID-19 pandemic.

Methods

The PEARL study (2016–2018) randomized OOHCA patients without ST-elevation to early cardiac catheterization or not. Community consultation included flyers, radio announcements, newspaper advertisements, mailings, and in-person surveys at basketball games and ED waiting rooms. The PROTECT trial (2021-present) randomizes OOHCA survivors to prophylactic ceftriaxone or placebo; the community consultation plan during the pandemic included city council presentations, social media posts, outpatient flyers, but no in-person encounters. Demographics for PROTECT community consultation were compared to PEARL and INTCAR registry data, with p-value < 0.05 considered significant.

Results

PEARL surveyed 1,362 adults, including 64 % ≥60 years old, 96 % high school graduates or beyond; research acceptance rate was 92 % for the community and 76 % for personal level. PROTECT initially obtained 221 surveys from electronic media – including fewer males (28 % vs 72 %,p < 0.001) and those > 60 years old (14 % vs 53 %;p < 0.001) compared to INTCAR. These differences prompted a revised community consultation plan, targeting 79 adult in-patients with cardiac disease which better matched PEARL and INTCAR data: the majority were ≥ 60 years old (66 %) and male (54 %). Both PEARL and PROTECT enrolled more patients using surrogate consent vs EFIC (57 %, 61 %), including 71 % as remote electronic consents during PROTECT.

Conclusions

Community consultation for EFIC studies changed with the COVID-19 pandemic, resulting in different demographic patterns. We describe effective adaptations to community consultation and surrogate consent during the pandemic.

Ethical Considerations in Clinical Trials for Disorders of Consciousness

As the clinical trial landscape for patients with disorders of consciousness (DoC) expands, consideration of associated ethical challenges and opportunities is of ever-increasing importance. Responsible conduct of research in the vulnerable population of persons with DoC, including those with coma, vegetative state/unresponsive wakefulness syndrome (VS/UWS), minimally conscious state (MCS), covert cortical processing (CCP), and cognitive motor dissociation (CMD), demands proactive deliberation of unique ethical issues that may arise and the adoption of robust protections to safeguard patients, surrogates, and other key stakeholders. Here we identify and critically evaluate four central categories of ethical considerations in clinical trials involving participants with DoC: (1) autonomy, respect for persons and informed consent of individuals with liminal consciousness; (2) balancing unknown benefits and risks, especially considering the epistemological gap between behavior and consciousness that complicates ordinary ascription of subjective states; (3) disclosure to surrogates and clinical teams of investigational results pertaining to consciousness; and (4) justice considerations, including equitable access to clinical trial enrollment across communities and geographies. We outline guiding principles and research opportunities for clinicians, neuroethicists, and researchers engaged in DoC clinical trials to advance ethical study design and deployment in this complex yet crucial area of investigation.