FOCUS ON THE PROCESS
The original intent of the informed consent (IC) process and related documents was to provide the participant with clear, accurate information on trial specifics and risks/benefits to aid in the decision to participate; however, the IC process has become burdensome and often does not meet the needs of prospective trial participants. For these reasons, CTTI sought to define the specific barriers to successful IC processes and propose solutions to optimize this process and enhance participant understanding of trial information to inform their decision-making process.
As detailed in the official CTTI recommendations, suggestions for improvement in the IC process focus on four key themes:
Implementing such changes is expected to promote a research culture that facilitates health-literate IC.
Jim Kremidas, ACRP Executive Director
“The Association of Clinical Research Professionals (ACRP) supports the recommendations put forth by our partners in the Clinical Trials Transformation Initiative,” says Jim Kremidas, ACRP Executive Director. “We are confident these recommendations will result in a more efficient and higher quality informed consent process conducted by clinical research professionals. A clear understanding of the risks and expectations clinical trial participants face will enhance their experience and drive better quality research.”
Helen K. Donnelly, RN, BSN, CCRC, Clinical Research Nurse, Pulmonary and Critical Care Medicine, Northwestern University
“As a study coordinator, I view the CTTI recommendations for a more comprehensive training program, including continuing education, as incredibly valuable and supportive of our needs. Additionally the discussion tool will assist in the training of new coordinators and help them assess the learning and communication needs of the study participant.”
In accordance with medical ethics regarding research on human subjects and federal regulatory requirements, it is necessary to obtain IC from prospective clinical trial participants. Required elements of IC in health research governed by US Federal Regulations, including FDA regulations and the Common Rule, are clearly described, yet the current IC process is often not meeting the needs of research participants in that is remains unclear how much prospective research participants understand. Informed consent documents (ICDs) are lengthy and may be difficult for patients to comprehend. Institutionally-required legal language is often inserted into ICDs, creating confusion about whether the ICD’s purpose is to clearly inform the patient or to serve institutional needs. Various groups have taken measures to address these concerns, but deficiencies with the process still exist. Issues surrounding re-consent of research participants, as well as when consent is required in a learning system of health care, are related issues but are outside the scope of this project.
Informed Consent (2013 - 2016)
Completion of the CTTI Informed Consent project will lead to a higher quality IC process.
Application of the CTTI IC Recommendations may lead to the following improvements:
Evidence from the literature review suggests that IRB-, sponsor-, and site-related operational barriers exist, along with an inadequate understanding of what patients want from the IC process. No single proven tool for measuring the quality of IC or effectiveness of consent interventions was cited in the literature. Limited, available evidence suggests that the current consent process has direct consequences on the ability to conduct clinical trials. The analysis of the literature review was published in May, 2016. The published results from the expert interviews supported these literature review findings and expanded on identified barriers.
All interviewees agreed that IC is essential to the protection of research participants; however, most acknowledged that the IC process in the United States has evolved into a rigid and cumbersome process that requires immediate attention and reform. Interviewees expressed consensus on three major themes: a new approach to the ICD, enhancing participant understanding of the clinical research, and modification of IRB review.
Some barriers that result in lengthy, variable, and overly complicated ICDs include the following:
Staff-related barriers to a successful IC process tend to more commonly result in participant dissatisfaction due to unmet emotional needs or lack of relevant trial information. These barriers include the following:
To address these barriers, experts explored new approaches to the IC process that focused on enhancing trial participant understanding. The most frequent recommendation for a single actionable change was to reform the ICD required for federally regulated research by making it simpler, shorter, and more understandable. Following this, interviewees proposed multiple strategies to create a more interactive and ongoing IC process to enhance research participant understanding. Some strategies include improving staff training on the conduct of an IC discussion, allowing adequate time and selecting the appropriate setting for the discussion, and providing an opportunity for prospective research participants to speak with other participants as a resource for information. Evaluating participants’ understanding was another topic that experts discussed during the interview. Several interviewees proposed that research participants’ comprehension about the clinical investigation be evaluated. A third consensus issue from the interviews was the need for modification of practices in IRB review of clinical research. Aligned with recommendations from the CTTI Central IRB projects, the most substantive expert recommendation was implementation of a single IRB of record for multi-site clinical trials.
Current Relevant FDA and DHHS Regulations:
|Team Member||Fred Bloom||CDC|
|Team Member||Zachary Hallinan||CISCRP|
|Team Member||Annick Anderson||CISCRP|
|Project Manager||Annemarie Forrest||Clinical Trials Transformation Initiative|
|Team Member||Ross McKinney||Duke University|
|Team Member||Kevin Hudziak||Eli Lilly|
|Team Leader||Jennifer Lentz||Eli Lilly|
|Team Member||Hallie Kassan||Feinstein Institute for Medical Research|
|Team Member||Marsha Melvin||Food and Drug Administration|
|Team Member||Rose Tiernan||Food and Drug Administration|
|Team Member||Kaveeta Vasisht||Food and Drug Administration|
|Team Member||Karim Calis||Food and Drug Administration|
|Team Member||Molly Flannery||Food and Drug Administration|
|Team Member||Cheryl Grandinetti||Food and Drug Administration|
|Team Member||Sheila Young||GlaxoSmithKline|
|Team Member||Stephen Mikita||Individual Patient/Caregiver|
|Team Member||Linda Morgan||Individual Patient/Caregiver|
|Team Leader||Jane Perlmutter||Individual Patient/Caregiver|
|Team Member||Beverly Lorell||King & Spaulding|
|Team Member||Julia Gorey||Office for Human Research Protections|
|Team Member||Jayvant Heera||Pfizer Inc|
|Team Member||Seth Schulman||Pfizer Inc|
|Team Member||Steve Cummings||University of California, San Francisco|
|Team Leader||Michele Kennett||University of Missouri|