Survey of u.s. Human research protection organizations: workload and membership

Health care ethics programs in U.S. Hospitals: results from a National Survey

BACKGROUND

As hospitals have grown more complex, the ethical concerns they confront have grown correspondingly complicated. Many hospitals have consequently developed health care ethics programs (HCEPs) that include far more than ethics consultation services alone. Yet systematic research on these programs is lacking.

METHODS

Based on a national, cross-sectional survey of a stratified sample of 600 US hospitals, we report on the prevalence, scope, activities, staffing, workload, financial compensation, and greatest challenges facing HCEPs.

RESULTS

Among 372 hospitals whose informants responded to an online survey, 97% of hospitals have HCEPs. Their scope includes clinical ethics functions in virtually all hospitals, but includes other functions in far fewer hospitals: ethical leadership (35.7%), regulatory compliance (29.0%), business ethics (26.2%), and research ethics (12.6%). HCEPs are responsible for providing ongoing ethics education to various target audiences including all staff (77.0%), nurses (59.9%), staff physicians (49.0%), hospital leadership (44.2%), medical residents (20.3%) and the community/general public (18.4%). HCEPs staff are most commonly involved in policy work through review of existing policies but are less often involved in development of new policies. HCEPs have an ethics representative in executive leadership in 80.5% of hospitals, have representation on other hospital committees in 40.7%, are actively engaged in community outreach in 22.6%, and lead large-scale ethics quality improvement initiatives in 17.7%. In general, major teaching hospitals and urban hospitals have the most highly integrated ethics programs with the broadest scope and greatest number of activities. Larger hospitals, academically affiliated hospitals, and urban hospitals have significantly more individuals performing HCEP work and significantly more individuals receiving financial compensation specifically for that work. Overall, the most common greatest challenge facing HCEPs is resource shortages, whereas underutilization is the most common greatest challenge for hospitals with fewer than 100 beds. Respondents' strategies for managing challenges include staff training and additional funds.

CONCLUSIONS

While this study must be cautiously interpreted due to its limitations, the findings may be useful for understanding the characteristics of HCEPs in US hospitals and the factors associated with these characteristics. This information may contribute to exploring ways to strengthen HCEPs.

Barriers to conducting a multi-center randomized controlled trial of surgical stabilization of rib fractures (and how to overcome them)

Surgical stabilization of rib fractures (SSRF) has become a standardized procedure, routinely performed at trauma centers over the last 40 years, however, it remains a controversial practice. Multicenter, randomized controlled trials (RCT) would provide compelling evidence in the efficacy of SSRF but there are theoretical obstacles involved with execution and design of this type of investigation. Through the systematic review of current literature on the topics of SSRF for flail and non-fail patterns, medical device industry conflicts of interests, working with international review boards (IRB), the surveyed opinions of surgeons, and through the experience gained from conducting a multicenter RCT on SSRF, it was possible to identify the major barriers that come with successful implementation of this type of study. In identifying these obstacles, it was then possible to propose their solutions, specifically to the issues that make the effort underpowered, underfunded, understaffed, with not enough time for completion. These barriers can be overcome with understanding, up front, that a mutlicenter RCT of SSRF will involve a multi-year and multi-hundred thousand dollar commitment, with support from parent organizations, and a dedicated, full-time research staff (and the solutions of how to overcome them). These barriers stem from poor planning which result specifically in an effort that is underpowered, under funded, under staffed, with not enough time for completion.

A multisite study of performance drivers among institutional review boards

Introduction

The time required to obtain Institutional Review Board (IRB) approval is a frequent subject of efforts to reduce unnecessary delays in initiating clinical trials. This study was conducted by and for IRB directors to better understand factors affecting approval times as a first step in developing a quality improvement framework.

Methods

807 IRB-approved clinical trials from 5 University of California campuses were analyzed to identify operational and clinical trial characteristics influencing IRB approval times.

Results

High workloads, low staff ratios, limited training, and the number and types of ancillary reviews resulted in longer approval times. Biosafety reviews and the need for billing coverage analysis were ancillary reviews that contributed to the longest delays. Federally funded and multisite clinical trials had shorter approval times. Variability in between individual committees at each institution reviewing phase 3 multisite clinical trials also contributed to delays for some protocols. Accreditation was not associated with shorter approval times.

Conclusions

Reducing unnecessary delays in obtaining IRB approval will require a quality improvement framework that considers operational and study characteristics as well as the larger institutional regulatory environment.

Applications for Research Concerning Fetal or Placental Tissue and Expected Institutional Review Board Responses

Proposals for research concerning fetal and/or placental tissue may be refused institutional review board (IRB) review, effectively preventing the research from occurring. We conducted an anonymous electronic survey of IRB chairs to determine their assessment of the likely response to research projects using fetal/placental tissue obtained from various procedures. We found that proposals concerning tissue obtained from diagnostic procedures or miscarriage were anticipated to be considered at most institutions. Tissue obtained after abortion was likely to be refused consideration by more than 25% of respondents. Additional consultation during review was anticipated for up to 30% of scenarios. Responses for fetal and placental tissue were similar. The most frequently anticipated reason for refusal was institutional policy.

Time required to review research protocols at 10 Veterans Affairs Institutional Review Boards

BACKGROUND

Despite perceptions that institutional review boards (IRBs) delay research, little is known about how long it takes to secure IRB approval. We retrospectively quantified IRB review times at 10 large Veterans Affairs (VA) IRBs.

METHODS

We collected IRB records pertaining to a stratified random sample of research protocols drawn from 10 of the 26 largest VA IRBs. Two independent analysts abstracted dates from the IRB records, from which we calculated overall and incremental review times. We used multivariable linear regression to assess variation in total and incremental review times by IRB and review level (i.e., exempt, expedited, or full board) and to identify potential targets for efforts to improve the efficiency and uniformity of the IRB review process.

RESULTS

In a sample of 277 protocols, the mean review time was 112 d (95% confidence interval [CI]: 105-120). Compared with full-board reviews at IRB 1, average review times at IRBs 3, 8, 9, and 10 were 27 (95% CI: 6-48), 37 (95% CI: 11-63), 45 (95% CI: 20-69), and 24 (95% CI: 2-45) d shorter, and at IRB 6, times were 56 (95% CI: 28-84) d longer. Across all IRBs, expedited reviews were 44 (95% CI: 30-58) d shorter on average than were full-board reviews, with no significant difference between exempt and full-board reviews. However, after subtracting the time required for Research and Development Committee review, exempt reviews were 21 (95% CI: 1-41) d shorter on average than were full-board reviews.

CONCLUSIONS

IRB review times differ significantly by IRB and review level. Few VA IRBs approach a consensus panel goal of 60 d for IRB review. The unexpectedly longer review times for exempt protocols in the VA can be attributed to time required for Research and Development Committee review. Prospective, routine collection of key time points in the IRB review process could inform IRB-specific initiatives for reducing VA IRB review times.

Institutional Board Review for Clinical Investigations on Inflammatory Bowel Diseases: A Single-Center Study

Background/Aims

The growing volume and the diversity of clinical research has led to related laws and regulations as well as the Institutional Review Board (IRB) approval process becoming more stringent. To conduct clinical research efficiently and while following regulations, information about the IRB approval process and feedback is important for investigators. This has yet to be studied.

Methods

We included 381 gastrointestinal disease research proposals (79 with inflammatory bowel disease [IBD], and 302 with non-IBD) reviewed by the IRB of Severance Hospital between January 2009 and December 2013. We retrospectively analyzed research characteristics including research risk levels, results of initial reviews, frequencies of continuing review, numbers of IRB comments, frequencies of IRB comments, and durations from submission to approval.

Results

Investigators' decisions on risk level were higher in the IBD group than in the non-IBD group (P<0.05). Results of initial reviews, frequencies of continuing reviews, the numbers of IRB review comments, and durations from submission to approval were not different between the two groups, but IRB decisions on risk level were higher in the IBD group (P<0.05). In subgroup analysis, the number of IRB comments from initial review on informed consent forms and procedures as well were quest of more information were significantly higher in the IBD group than in the non-IBD group (P<0.001 and 0.01, respectively).

Conclusions

In Korea, rare diseases such as IBD require more information for the IRB process due to their distinct characteristics. IBD researchers should develop research protocols more carefully and make their research as subject-friendly as possible.

A domain analysis model for eIRB systems: addressing the weak link in clinical research informatics

Institutional Review Boards (IRBs) are a critical component of clinical research and can become a significant bottleneck due to the dramatic increase, in both volume and complexity of clinical research. Despite the interest in developing clinical research informatics (CRI) systems and supporting data standards to increase clinical research efficiency and interoperability, informatics research in the IRB domain has not attracted much attention in the scientific community. The lack of standardized and structured application forms across different IRBs causes inefficient and inconsistent proposal reviews and cumbersome workflows. These issues are even more prominent in multi-institutional clinical research that is rapidly becoming the norm. This paper proposes and evaluates a domain analysis model for electronic IRB (eIRB) systems, paving the way for streamlined clinical research workflow via integration with other CRI systems and improved IRB application throughput via computer-assisted decision support.

Is your ethics committee efficient? Using "IRB Metrics" as a self-assessment tool for continuous improvement at the Faculty of Tropical Medicine, Mahidol University, Thailand

Tensions between researchers and ethics committees have been reported in several institutions. Some reports suggest researchers lack confidence in the quality of institutional review board (IRB) reviews, and that emphasis on strict procedural compliance and ethical issues raised by the IRB might unintentionally lead to delays in correspondence between researchers and ethics committees, and/or even encourage prevarication/equivocation, if researchers perceive committee concerns and criticisms unjust. This study systematically analyzed the efficiency of different IRB functions, and the relationship between efficiency and perceived quality of the decision-making process. The major purposes of this study were thus (1) to use the IRB Metrics developed by the Faculty of Tropical Medicine, Mahidol University, Thailand (FTM-EC) to assess the operational efficiency and perceived effectiveness of its ethics committees, and (2) to determine ethical issues that may cause the duration of approval process to be above the target limit of 60 days. Based on a literature review of definitions and methods used and proposed for use, in assessing aspects of IRB quality, an “IRB Metrics” was developed to assess IRB processes using a structure-process-outcome measurement model. To observe trends in the indicators evaluated, data related to all protocols submitted to the two panels of the FTM-EC (clinical and non-clinical), between January 2010–September 2013, were extracted and analyzed. Quantitative information based on IRB Metrics structure-process-outcome illuminates different areas for internal-process improvement. Ethical issues raised with researchers by the IRB, which were associated with the duration of the approval process in protocol review, could be considered root causes of tensions between the parties. The assessment of IRB structure-process-outcome thus provides a valuable opportunity to strengthen relationships and reduce conflicts between IRBs and researchers, with positive outcomes for all parties involved in the conduct of human-subject research.

Survey of U.S. Boards that Review Mental Health-related Research

WE OBTAINED DATA ON INSTITUTIONAL Review Boards (IRBs) that review mental health-related applications (MHRAs) in a national survey of institutions with federally assured human research protection programs. Approximately 57% of IRBs review MHRAs, and among these a small percentage may not have mental health experts on their committees (5%). Moreover, mental health experts on IRB committees at high research volume institutions are carrying substantially greater workloads than their lower volume counterparts. In terms of committee demographics, more women (36%) are serving as IRB Chairs on committees that review MHRAs than expected from their representation on medical or university faculties; ethnic minority faculty have lower representation among Chairs than might be expected from their overall faculty representation. Our findings suggest the need for additional studies to (a) examine if the number of mental health experts on IRBs should be increased particularly among IRBs reviewing a high volume of MHRAs, (b) determine if the breadth of expertise among IRB mental health experts corresponds to the range of substantive and methodological approaches represented by the mental health protocols under review, and (c) examine if recruiting IRB scientific expertise from outside an institution, a more common practice among smaller research entities, impacts review quality.

The silent majority: who speaks at IRB meetings?

Institutional review boards (IRBs) are almost universally considered over-worked and under-staffed, at the same time requiring substantial commitments of time and resources. Although some surveys report average IRB memberships of 15 persons or more, federal regulations require only five. We present data on IRB meetings at 8 of the top 25 NIH-funded academic medical centers in the U.S., indicating substantial contributions from primary reviewers and chairs during protocol discussions but little from other members. The implications of these data for current IRB functioning are discussed and an alternative model proposed.

How closely do institutional review boards follow the common rule?

PURPOSE

To determine how closely institutional review board (IRB) discussions reflect the ethical criteria specified in the Common Rule federal regulations.

METHOD

Between November 2006 and July 2009, the authors observed, audio-recorded, transcribed, and coded protocol reviews from 20 IRB meetings at 10 leading academic medical centers. They also reviewed each of the applications discussed to identify the Common Rule criteria-(1) risk minimization, (2) risk/benefit comparison, (3) equitable subject selection, (4) informed consent, (5) data monitoring to ensure safety, (6) privacy protection and confidentiality, and (7) protection of vulnerable subjects-that were both relevant to the study and not adequately addressed in the application. They then determined if the IRB addressed each of the relevant and not-discussed Common Rule criteria in their discussions.

RESULTS

IRBs made no mention of many of the Common Rule criteria that required their discussion-In 17/82 (21%) reviews, they failed to address risk minimization; in 52/91 (57%), risk/benefit comparison; in 31/52 (60%), equitable subject selection; in 32/59 (54%), data monitoring; in 13/52 (25%), privacy and confidentiality; and in 7/55 (13%), protection of vulnerable populations. However, they discussed informed consent in 102/104 (98%) reviews and raised questions about, or requested changes about, informed consent for 92/104 (88%) protocols.

CONCLUSIONS

These findings suggest that essential elements of human subjects protection are not implemented uniformly across IRBs. Although not directly addressing this issue, the current proposed changes to the Common Rule offer an opportunity to improve, in general, the effectiveness of IRBs to protect human subjects.

Burdens on research imposed by institutional review boards: the state of the evidence and its implications for regulatory reform

CONTEXT

Federal regulations mandate independent review and approval by an "institutional review board" (IRB) before studies that involve human research subjects may begin. Although many researchers strongly support the need for IRB review, they also contend that it is burdensome when it imposes costs that do not add to the protections afforded to research participants and that this burden threatens the viability of research. The U.S. Department of Health and Human Services recently announced its intention to reform the regulations governing IRB review.

METHODS

We used a search of the PubMed database, supplemented by a bibliographic review, to identify all existing primary data on the costs of IRB review. "Costs" were broadly defined to include both expenditures of time or money and constraints imposed on the scope of the research. Burdensome costs were limited to those that did not contribute to greater protections for the participants.

FINDINGS

Evidence from a total of fifty-two studies shows that IRBs operate at different levels of efficiency; that waiting to obtain IRB approval has, in some instances, delayed project initiation; that IRBs presented with identical protocols sometimes asked for different and even competing revisions; and that some decisions made (and positions held) by IRBs are not in accord with federal policy guidance.

CONCLUSIONS

While the evidence is sufficient to conclude that there is burden associated with IRB review, it is too limited to allow for valid estimates of its magnitude or to serve as the basis for formulating policies on IRB reform. The single exception is multicenter research, for which we found that review by several local IRBs is likely to be burdensome. No mechanism currently exists at the national level to gather systematic evidence on the intersection between research and IRB review. This gap is of concern in light of the changing nature of research and the increasingly important role that research is envisioned to play in improving the overall quality of health care.

How Do IRB Members Make Decisions? A Review and Research Agenda

Many factors have been found to influence the nature and quality of the human research ethics review process. These are reviewed along with discussion of ways in which normal psychological characteristics and group decision-making processes may affect the decisions of institutional review board (IRB) members when reviewing proposed research activities, and may contribute to the acknowledged variability of IRB responses to identical research proposals. Three salient features of human judgment and decision-making illuminated by the existing psychological research literature are used to illustrate this idea: Research findings related to (a) risk perception and acceptance, (b) the standards people use to make decisions, and (c) some nonrational influences on group decision-making suggest how psychological characteristics may affect some outcomes of convened IRB meetings. Recognizing such influences may enable the improvement of IRB decision-making.

The research ethics committee is not the enemy: oversight of community-based participatory research

Researchers conducting community-based participatory research (CBPR) often complain about research ethics committee (REC) oversight of their research. RECs may contribute to researchers' frustrations by seemingly focusing on form over substance and by failing to communicate effectively with researchers about their mission and their specific concerns. UCSF CBPR researchers presented their views of the UCSF REC's review of its tobacco use study in "It's Like Tuskegee in Reverse: A Case Study of Ethical Tensions in Institutional Review Board Review of Community-Based Participatory Research." This article builds on that case study by providing some perspectives from the REC side, identifying how the researchers and the REC came to be at odds, and seeking to bridge the gap between the CBPR and REC worlds. In particular, the article explores the different perspectives on who are human subjects under the federal regulations in CBPR research, who counts as the community, and the purpose of REC oversight. It offers concrete suggestions for improving the relationship between CBPR researchers and RECs.