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Abstract
BACKGROUND Informed consent documents for clinical studies should disclose all reasonably foreseeable risks and benefits. Little guidance exists on how to navigate the complexities of risk-benefit communication, especially in early clinical research. Practice-oriented development of such guidance should be informed by evidence on what and how details of risks and benefits are currently communicated. METHOD We surveyed the responsible parties of phase I/II trials registered in ClinicalTrials.gov that started 2007 or later and completed between 2012 and 2016 to sample informed consent documents from a broad spectrum of early phase clinical trials. Based on an assessment matrix, we qualitatively and quantitatively assessed the informed consent documents for details of risk-benefit communication. RESULTS The risk-benefit communication in the 172 informed consent documents differed substantially in several regards. The outcome, extent, and likelihood of health risks, for example, were described in 83%, 32%, and 63% of the informed consent documents. Only 45% of informed consent documents specified the outcome of mentioned health benefits, and the extent and likelihood of health benefits were never specified. From those informed consent documents reporting risk likelihoods, only 57% added frequency numbers to words such as "common" or "rare," and even in these cases, we found strong variations for presented frequency ranges. Substantial heterogeneity also exists for how informed consent documents communicate other risk and benefit types and related safeguards. CONCLUSION Our study points to several shortcomings and heterogeneities in how informed consent documents communicate risks and benefits to potential research participants. Health risks, for example, should be specified with frequency numbers, and health benefits should be specified at least by mentioning their outcomes. Further demand for research and policy development is needed to harmonize risk-benefit communication and to clarify ways to specify the likelihood of health benefits.
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Affiliation(s)
- Hannes Kahrass
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Sabine Bossert
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany.,Forschungszentrum Jülich, Jülich, Germany
| | - Christopher Schürmann
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Daniel Strech
- Institute for History, Ethics and Philosophy of Medicine, Hannover Medical School, Hannover, Germany.,QUEST Center, Berlin Institute of Health (BIH), Berlin, Germany.,Charité-Universitätsmedizin-Berlin, Berlin, Germany
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Abraham NS, Naik AD, Street RL, Castillo DL, Deswal A, Richardson PA, Hartman CM, Shelton G, Fraenkel L. Complex antithrombotic therapy: determinants of patient preference and impact on medication adherence. Patient Prefer Adherence 2015; 9:1657-68. [PMID: 26640372 PMCID: PMC4657793 DOI: 10.2147/ppa.s91553] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE For years, older patients have been prescribed multiple blood-thinning medications (complex antithrombotic therapy [CAT]) to decrease their risk of cardiovascular events. These therapies, however, increase risk of adverse bleeding events. We assessed patient-reported trade-offs between cardioprotective benefit, gastrointestinal bleeding risk, and burden of self-management using adaptive conjoint analysis (ACA). As ACA could be a clinically useful tool to obtain patient preferences and guide future patient-centered care, we examined the clinical application of ACA to obtain patient preferences and the impact of ACA on medication adherence. PATIENTS AND METHODS An electronic ACA survey led 201 respondents through medication risk-benefit trade-offs, revealing patients' preferences for the CAT risk/benefit profile they valued most. The post-ACA prescription regimen was categorized as concordant or discordant with elicited preferences. Adherence was measured using VA pharmacy refill data to measure persistence of use prior to and 1 year following preference-elicitation. Additionally, we analyzed qualitative interviews of 56 respondents regarding their perception of the ACA and the preference elicitation experience. RESULTS Participants prioritized 5-year cardiovascular benefit over preventing adverse events. Medication side effects, medication-associated activity restrictions, and regimen complexity were less important than bleeding risk and cardioprotective benefit. One year after the ACA survey, a 15% increase in adherence was observed in patients prescribed a preference-concordant CAT strategy. An increase of only 6% was noted in patients prescribed a preference-discordant strategy. Qualitative interviews showed that the ACA exercise contributed to increase inpatient activation, patient awareness of preferences, and patient engagement with clinicians about treatment decisions. CONCLUSION By working through trade-offs, patients actively clarified their preferences, learning about CAT risks, benefits, and self-management. Patients with medication regimens concordant with their preferences had increased medication adherence at 1 year compared to those with discordant medication regimens. The ACA task improved adherence through enhanced patient engagement regarding treatment preferences.
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Affiliation(s)
- Neena S Abraham
- Division of Gastroenterology, Mayo Clinic, Scottsdale, AZ, USA
- Divison of Healthcare Policy and Research, Department of Health Services Research, Rochester, MN, USA
- Correspondence: Neena S Abraham, Division of Gastroenterology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA, Tel +1 480 301 6990, Fax +1 480 301 8673, Email
| | - Aanand D Naik
- Center for Innovations in Quality, Effectiveness, and Safety at the Michael E DeBakey VA Medical Center, Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Richard L Street
- Center for Innovations in Quality, Effectiveness, and Safety at the Michael E DeBakey VA Medical Center, Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Department of Communication, Texas A&M University, College Station, TX, USA
| | - Diana L Castillo
- Center for Innovations in Quality, Effectiveness, and Safety at the Michael E DeBakey VA Medical Center, Houston, TX, USA
| | - Anita Deswal
- Cardiology, Michael E DeBakey VAMC, Houston, TX, USA
| | - Peter A Richardson
- Center for Innovations in Quality, Effectiveness, and Safety at the Michael E DeBakey VA Medical Center, Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Christine M Hartman
- Center for Innovations in Quality, Effectiveness, and Safety at the Michael E DeBakey VA Medical Center, Houston, TX, USA
| | - George Shelton
- Center for Innovations in Quality, Effectiveness, and Safety at the Michael E DeBakey VA Medical Center, Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Liana Fraenkel
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale University, New Haven, CT, USA
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