Plain Language Summaries of Clinical Trial Results: A Preliminary Study to Assess Availability of Easy-to-Understand Summaries and Approaches to Improving Public Engagement

BACKGROUND

Easy-to-understand, stand-alone factual summaries of clinical trial results have the potential to improve public understanding of and engagement with pharmaceutical research. The European Clinical Trial Regulation (EU) No. 536/2014 is a major regulatory initiative that will result in a large number of such plain language summaries (PLSs) posted in the public domain. Today, however, little is known about the extent to which PLSs are written and are available to the general public.

OBJECTIVES

This preliminary study assessed (i) 20 top pharmaceutical companies' positions on improving transparency and commitment to disclosing trial result summaries in an easy-to-understand format and (ii) the availability of such summaries in the public domain and the ease of locating them via general web searches.

METHODS

The availability of PLSs in the public domain was estimated based on the number of EudraCT technical result summaries in four disease areas: chronic obstructive pulmonary disease, asthma, meningitis, and influenza. The likelihood of PLSs being easy to find through internet search engine queries by members of the public was assessed using Google.

RESULTS

All 20 sponsors had committed to improve clinical trial transparency, 17 committed to sharing PLSs with trial participants, and 14 had at least one PLS available in the public domain. A total of 99 clinical studies in these four disease areas had technical summaries posted on EudraCT between 1 January 2017 and 30 June 2020. Of these 99, 14 studies had PLSs in the public domain. A total of 12 of 14 PLSs were directly captured by search engine. However, the sponsor trial identifier or EudraCT number had to be included in the search term to locate them. Generic search terms resulted in large volumes of non-relevant results.

CONCLUSION

Despite the progressive movement towards clinical trial transparency, easily accessible PLSs on clinical trials are currently scarce. The provision of a European mandate and framework for non-technical result summaries by Regulation (EU) 536/2014 will be a major step to bring about positive change.

LeRoy Walters's Legacy of Bioethics in Genetics and Biotechnology Policy

LeRoy Walters was at the center of public debate about emerging biological technologies, even as "biotechnology" began to take root. He chaired advisory panels on human gene therapy, the human genome project, and patenting DNA for the congressional Office of Technology Assessment. He chaired the subcommittee on Human Gene Therapy for NIH's Recombinant DNA Advisory Committee. He was also a regular advisor to Congress, the executive branch, and academics concerned about policy governing emerging biotechnologies. In large part due to Prof. Walters, the Kennedy Institute of Ethics was one of the primary sources of talent in bioethics, including staff who populated policy and science agencies dealing with reproductive and genetic technologies, such as NIH and OTA. His legacy lies not only in his writings, but in those people, documents, and discussions that guided biotechnology policy in the United States for three decades.

United States Food and Drug Administration Advisory Committee outcomes and agency approval analysis from 2010 to 2015

OBJECTIVES

This analysis sought to quantify voting behavior and other characteristics of advisory committee (AC) meetings and compare that with the U.S. Food and Drug Administration's (FDA) approval decisions from 2010 to 2015.

METHODS

The analysis of the Center for Drug Evaluation and Research AC meetings was conducted using publicly available information from the FDA website and the sponsors' websites.

RESULTS

There were 163 voting sessions, 207 votes, and 229 meetings. Voting questions assessed approval (63%), acceptable risk-benefit profile (19%), efficacy (8%), safety and efficacy (7%), and safety (3%). The AC voted in favor of approval 67% of the time and against approval 33% of the time, although it heavily favored one outcome when voting favorably or unfavorably. The FDA approval decision supported the committee's decision in 90% of cases. When such agreement did not occur, it was due to differences in clinical opinion (43%), manufacturing deficiencies (14%), lack of manufacturing data (14%), and a post-AC event (5%). There was insufficient information to determine why there was a differing opinion in 24% of cases. When FDA had a differing opinion, the agency typically did not approve a substance in which the committee recommended approval (81%).

CONCLUSION

The results support past research examining the topic from 2001 to 2010. Voting patterns were relatively constant, and they generally heavily favored one outcome. The FDA's ultimate approval decision was in line with the AC vote the vast majority of cases. Any disagreement was usually due to FDA having a differing opinion regarding clinical importance, furthering the notion that AC insight is heavily considered but not the final determinant in agency action. This topic has importance in understanding pharmaceutical approval in the United States, and this has clinical practice implications.

Clinic, courtroom or (specialist) committee: in the best interests of the critically Ill child?

Law's processes are likely always to be needed when particularly intractable conflicts arise in relation to the care of a critically ill child like Charlie Gard. Recourse to law has its merits, but it also imposes costs, and the courts' decisions about the best interests of such children appear to suffer from uncertainty, unpredictability and insufficiency. The insufficiency arises from the courts' apparent reluctance to enter into the ethical dimensions of such cases. Presuming that such reflection is warranted, this article explores alternatives to the courts, and in particular the merits of specialist ethics support services, which appear to be on the rise in the UK. Such specialist services show promise, as they are less formal and adversarial than the courts and they appear capable of offering expert ethical advice. However, further research is needed into such services - and into generalist ethics support services - in order to gauge whether this is indeed a promising development.

The impact of Australia's Royal Commission on child- and youth-serving organizations

This commentary considers the impact to date of Australia's Royal Commission into Institutional Responses to Child Sexual Abuse on child- and youth-serving organizations, particularly its influence on organizations' efforts to create and maintain 'child safe, child friendly' cultures, policies and practices. Opportunities and challenges for organizational leaders are outlined. The commentary calls for more involvement by researchers in empirical research that is relevant to the causes and prevention of abuse in organizations, and for findings to be disseminated in ways that are useful to organizations.

The Australian Royal Commission into Institutional Responses to Child Sexual Abuse and the Roman Catholic Church

The Australian Royal Commission into Institutional Responses to Child Sexual Abuse received more reports of sexual abuse of minors from victims of personnel from the Catholic Church than from any other source. It looked beyond the circumstances of the individual reports, to the response of Church leaders. It then took the inquiry to the more fundamental issue of the elements of the Church's structure and its unique culture that enabled sexual abuse and supported the hierarchy's counter-productive responses. This commentary looks at the structural and cultural aspects of the institutional Church most directly connected to sexual abuse by clerics and the ensuing cover-up and it examines their theological and historical foundations. The reality that sexual abuse by clerics was not only known but condoned and covered up cannot be justified but it can be explained in great part by the Church's justification for its own structure and the role of its clerics.

Optimising implementation of reforms to better prevent and respond to child sexual abuse in institutions: Insights from public health, regulatory theory, and Australia's Royal Commission

The Australian Royal Commission Into Institutional Responses to Child Sexual Abuse has identified multiple systemic failures to protect children in government and non-government organizations providing educational, religious, welfare, sporting, cultural, arts and recreational activities. Its recommendations for reform will aim to ensure organizations adopt more effective and ethical measures to prevent, identify and respond to child sexual abuse. However, apart from the question of what measures institutions should adopt, an under-explored question is how to implement and regulate those measures. Major challenges confronting reform include the diversity of organizations providing services to children; organizational resistance; and the need for effective oversight. Failure to adopt theoretically sound strategies to overcome implementation barriers will jeopardize reform and compromise reduction of institutional child sexual abuse. This article first explains the nature of the Royal Commission, and focuses on key findings from case studies and data analysis. It then analyzes public health theory and regulatory theory to present a novel analysis of theoretically justified approaches to the implementation of measures to prevent, identify and respond to CSA, while isolating challenges to implementation. The article reviews literature on challenges to reform and compliance, and on prevention of institutional CSA and situational crime prevention, to identify measures which have attracted emerging consensus as recommended practice. Finally, it applies its novel integration of regulatory theory and public health theory to the context of CSA in institutional contexts, to develop a theoretical basis for a model of implementation and regulation, and to indicate the nature and functions of a regulatory body for this context.

The Australian Royal Commission into Institutional Responses to Child Sexual Abuse

The Royal Commission into Institutional Responses to Child Sexual Abuse is the largest royal commission in Australia's history and one of the largest public inquiries into institutional child abuse internationally. With an investment from the Australian government of half a billion dollars, it examined how institutions with a responsibility for children, both historically and in the present, have responded to allegations of child sexual abuse. Announced in the wake of previous Australian and international inquiries, public scandals and lobbying by survivor groups, its establishment reflected increasing recognition of the often lifelong and intergenerational damage caused by childhood sexual abuse and a strong political commitment to improving child safety and wellbeing in Australia. This article outlines the background, key features and innovations of this landmark public inquiry, focusing in particular on its extensive research program. It considers its international significance and also serves as an introduction to this special edition on the Australian Royal Commission, exploring its implications for better understanding institutional child sexual abuse and its impacts, and for making institutions safer places for children in the future.

A comparison of decisions to discharge committed psychiatric patients between treating physicians and district psychiatric committees: an outcome study

BACKGROUND

The Israel Mental Health Act of 1991 stipulates a process for involuntary psychiatric hospitalization (IPH). A patient thus hospitalized may be discharged by either the treating psychiatrist (TP) or the district psychiatric committee (DPC). The decision rendered by the DPC is often at odds with the recommendation of the TP. Although much has been written about the ethical issues of restricting patients' rights and limiting their freedom, far less attention has been devoted to the psychiatric, medical, and social outcome of legal patient discharge against the doctor's recommendation.

METHODS

In our study we examined the outcomes of the decisions made by the DPC using readmission data, an internationally recognized indicator of the quality of hospital care, and compared them to the outcomes of patients discharged by the TP. All IPH discharges resulting from the DPC's determination for the year 2013 (N = 972) were extracted from the Israel national register. We also collected all IPH discharges owing to the TP's decision for 2013 (N = 5788). We defined "failure" as readmission in less than 30 days, involuntary civil readmission in less than 180 days, and involuntary readmission under court order in less than 1 year.

RESULTS

The rehospitalization pattern was compared in the two groups of patients discharged from their psychiatric hospitalization during 2013 (index discharges) and followed up individually for a year. We found a statistically significant difference between the DPC and the TP group for each of the time frames, with the DPC group returning to IPH much more frequently than the TP group. Using cross-sectional comparison with logistic regression adjusted for age, gender, diagnosis and length of hospitalization, we found the probability of a decision failure in the TP group was significantly less with an OR of 0.7 (95% CI .586-.863), representing a 30% adjusted decrease in the probability for failure in the TP group.

CONCLUSIONS

The results we present show that the probability of decision "failure" (readmission) was found to be significantly higher in the DPC group than in the TP group. It is often assumed that IPH patients will fare better at home in their communities than in a protracted hospitalization. This is frequently the rationale for early discharge by the DPC (30.1 days vs. 75.9 DPC and TP groups, respectively). Our results demonstrate that this rationale may well be a faulty generalization.

Drug approval status and recommendations for listing on public formularies: a Canadian cohort analysis

OBJECTIVES

Investigate if the recommendations by the Common Drug Review (CDR) and the pan-Canadian Oncology Drug Review (pCODR) to provincial, territorial and federal drug plans about whether to list non-oncology and oncology drug-indication combinations on their formularies are associated with whether the drug-indication combination was approved via the standard evidence pathway or the Notice of Compliance with conditions (NOC/c-limited evidence) pathway.

DESIGN

Cohort study.

DATA SOURCES

Websites of the CDR and pCODR up to the end of 31 March 2017; journal articles evaluating drugs approved through the NOC/c pathway, the NOC database, the NOC/c website and the Summary Basis of Decision website.

INTERVENTIONS

Recommendations by the CDR and pCODR.

PRIMARY AND SECONDARY OUTCOME MEASURES

Analysis of the percent of drugs receiving positive listing recommendations from CDR and pCODR depending on the pathway used to approve the drug.

RESULTS

There were 310 recommendations for drug-indication combinations from the CDR and 79 from the pCODR. There was a statistically significant difference in the number of drug-indication combinations that received a list versus do not list recommendation from the CDR for those approved through the standard pathway compared with those approved through the NOC/c pathway (p=0.0407). A similar analysis for recommendations from the pCODR was not statistically significant.

CONCLUSION

For non-oncology drug-indication combinations, the type of review appears to influence the recommendation regarding listing on public formularies. This difference may reflect the level of evidence about the efficacy and safety of the drug indication at the time the recommendation was made.

Insights and issues from FDA Advisory Committee meetings on abuse-deterrent opioids

It is the current policy of the US Food and Drug Administration (FDA) to convene expert Advisory Committees to provide input on key regulatory decisions regarding opioid products, including approval and labeling of opioid abuse-deterrent formulations (ADFs). Advisory Committee meetings on ADF opioids consider whether the laboratory and clinical data submitted by the sponsor are sufficient to support marketing approval and labeling of the product with properties expected to deter abuse by specific routes of abuse (ie, oral, intranasal, intravenous). The FDA has typically followed the approval and labeling recommendations for ADFs reviewed by its Advisory Committees, highlighting the importance of these meetings in the regulatory approval process. This review describes common issues considered by Advisory Committees for ADF opioids as well as insights on how to prepare for these meetings based on recent relevant experience and regulatory decisions.

Patient Engagement Advisory Committee. Final rule

The Food and Drug Administration (FDA) is amending the standing advisory committees' regulations to add the Patient Engagement Advisory Committee.

State Health Insurance Assistance Program (SHIP). Interim final rule

This rule implements a provision enacted by the Consolidated Appropriations Act of 2014 and reflects the transfer of the State Health Insurance Assistance Program (SHIP) from the Centers for Medicare & Medicaid Services (CMS), in the Department of Health and Human Services (HHS) to the Administration for Community Living (ACL) in HHS. The previous regulations were issued by CMS under the authority granted by the Omnibus Budget Reconciliation Act of 1990 (OBRA `90), Section 4360.

State Dental Boards and Public Protection: Fulfilling the Contract

Dental boards are agents of the state, sworn to protect the public. They combine the skills of professional training with responsibility to ensure that patients receive safe and effective care. They can play a vital role in ensuring that the profession does not invite more regulation by working to maintain the public's trust. Two cases are presented illustrating that one's perspective can cloud the sense of what is right and that it is wrong to pass ethical responsibilities on to others.

[Control of the legal practice of euthanasia in Belgium]

The Belgian law legalizing euthanasia under strict conditions came into effect September 22, 2002. Any physician performing euthanasia has to complete a registration document and to send it within four days to a federal commission whose mission is to verify that the legal conditions were fulfilled. From September 22, 2002 to December 31, 2013, 8.767 documents have been registered and analyzed by this commission. They are described in six reports referred to Parliament. The present paper analyzes the work of this commission and answers the criticisms concerning its quality and its efficiency. The allegations that clandestine euthanasia's escaping any control are performed are also discussed. In conclusion, it appears that the legal obligations concerning the practice of euthanasia in Belgium are fully effective.

Is anyone listening? Variation in PSA screening among providers for men 75+ before and after United States Preventive Services Task Force recommendations against it: a retrospective cohort study

Background

In 2008, the United States Preventive Services Task Force recommended against prostate specific antigen (PSA) testing for cancer screening in men age 75+.

Purpose

To assess PSA screening by primary care physicians (PCPs) before and after recommendations.

Methods

In 2013, this retrospective cohort study analyzed PCPs in Texas with 20+ male patients aged 75+ in both 2007 and 2010, with Parts A and B Medicare. The main outcome was percent of PCP’s male patients 75+ who received PSA testing ordered by the PCP in 2007 and 2010, with no recent symptoms suggestive of prostate cancer.

Results

In both 2007 and 2010, 1,083 PCPs cared for at least 20 men aged 75 or older. The rate of PSA screening ordered by PCPs was 33.2% in 2007 and 30.6% in 2010. In multilevel analyses controlling for patient characteristics, the variation in PSA screening attributable to the PCP (intraclass correlation coefficient) increased from 23% in 2007 to 26% in 2010, p<0.001. Men with PCPs older than age 60 had 9% lower odds (95% CI, 1–17%) in 2010 compared to 2007 of receiving a PSA test, vs. a 4% increase (95% CI, 4% decrease to 12% increase) in men with PCPs aged 50 or younger. Patients with Board Certified PCPs had a 12% lower odds (95% CI, 8% to 16%) from 2007 to 2010, vs. 2% increase (95% CI 11% decrease to 18% increase) in men with PCPs without board certification.

Conclusions

The USPSTF recommendation did not increase consensus among PCPs regarding PSA screening of older men.

Where does New Zealand stand on permitting research on human embryos?

In many respects New Zealand has responded to the assisted reproductive technologies (ARTs) as positively as many comparable societies, such as Australia and the UK. Consequently, in vitro fertilisation (IVF) and pre-implantation genetic diagnosis (PGD) are widely available, as is non-commercial surrogacy utilising IVF. These developments have been made possible by the Human Assisted Reproductive Technology (HART) Act 2004, overseen by its two committees, the Advisory Committee on Assisted Reproductive Technology (ACART) and the Ethics Committee (ECART). However, New Zealand stands apart from many of these other societies by the lack of permission for scientists to conduct research using human embryos. There is no doubt this reflects strongly held viewpoints on the part of some that embryos should be protected and not exploited. Legitimate as this stance is, the resulting situation is problematic when IVF is already designated as an established procedure. This is because the development of IVF involved embryo research, and continuing improvements in procedures depend upon ongoing embryo research. While prohibition of research on human embryos gives the impression of protecting embryos, it fails to do this and also fails to enhance the health and wellbeing of children born using IVF. This situation will not be rectified until research is allowed on human embryos.

Who are the PDCO?

In January 2007, the Paediatric Regulation entered into force and established the Paediatric Committee (PDCO) within the European Medicines Agency. The goal of the PDCO is to improve the health of the children of Europe by increasing high-quality research for medicinal products and promoting the development and authorization of such medicines at the EU level. A major function of the PDCO is to formulate and authorize Paediatric Investigation Plans and Paediatric Use Marketing Authorisations. The EU's Seventh Framework Programme for Research has facilitated the establishment of consortia whose ultimate goal is to answer important clinical questions involving medicines commonly used "off-label", in children. The benefits of these consortia include enhanced collaboration amongst paediatricians, scientists and small to medium enterprises whose ultimate goal is to obtain an authorization for a new indication or formulation for use in the paediatric population. It will be interesting in a number of years time to measure the success of this very important European initiative.

The Dutch Euthanasia Act: recent legal developments

The Dutch Termination of Life on Request and Assisted Suicide Act [Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding (Wtl)] came into force in 2002. Its aim is to increase the degree of due care exercised by physicians when terminating a patient's life and to provide a legal framework within which physicians account for their actions in such cases. On the basis of the second evaluation of the Act, published in December 2012, this article provides an overview of the most recent legal developments regarding the Dutch Euthanasia Act. Special attention is given to patients with dementia, psychiatric patients and patient who are "weary of life".