The Johns Hopkins Berman Institute of Bioethics invites applications for a Postdoctoral Fellowship in the Ethics and Regulatory Aspects of Pragmatic Clinical Trials. This position includes pursuing independent research, working alongside faculty members involved with the ethics and regulatory aspects of large-scale pragmatic clinical trials (PCTs), and participating in the Hecht-Levi Postdoctoral Fellowship in Bioethics. The postdoctoral fellow is expected to pursue one or more projects addressing the ethics and regulatory aspects of PCTs in collaboration with Berman Institute faculty members. The Fellow will actively engage with the Ethics and Regulatory Core of the NIH Health Care Systems Research Collaboratory and the Pragmatic and Implementation Studies for the Management of Pain to Reduce Opioid Prescribing (PRISM) Resource Coordinating Center.
Qualifications: Applications are welcome from candidates who will have an MD, PhD, or JD or their equivalent by the start date of the fellowship. Applicants should not have completed their terminal degree more than 3 years before the start date of the appointment. Physicians should not have completed a formal residency training program more than 3 years by the start date of the appointment.
Start date: September 1, 2020.
Terms of Appointment: The fellowship is guaranteed for 1 year with the expectation of a second year of funding, contingent on review. Applicants may not be employed by another institution and are expected to be in residence for the duration of the appointment.
At the May 2019 meeting of the NIH Collaboratory Steering Committee, we talked with Judith Carrithers, coleader of the Ethics and Regulatory Core. The task of the Core is to develop a framework for conducting embedded pragmatic clinical trials (ePCTs) in an ethical manner and in compliance with federal and state regulations. Ms. Carrithers joined the Core last year prior to the start of the yearlong planning phase for 6 new UG3 Demonstration Projects. We asked her to reflect on the Core’s progress and challenges during the past year.
Please tell us about the Core’s recent accomplishments.
The Ethics and Regulatory Core is learning how to frame ethical and regulatory issues around ePCTs while talking with each study team to learn how their trial is going to work, what informed consent considerations they may have, and, for their population, what makes the most sense within the regulatory framework. By the time I joined, the Core had already gone through the first round of UH3 Demonstration Projects, and I was able to piggyback on the learning from that experience, which informed our interviews and discussions with the new UG3 studies last summer. The regulatory framework we’re working in is a little black, a little white—and a lot of gray. For ePCTs, and clinical trials in general, within that framework there are things it’s clear you can do and cannot do, and a lot of things where you’re using your best judgment in the context of a study.
“The regulatory framework we’re working in is a little black, a little white—and a lot of gray.”
What we see with pragmatic trials across those conducted in the Collaboratory is that many are clearly minimal-risk studies, so there is the possibility of managing informed consent in a different way. A written consent form is generally required under the federal regulations for studies that present more than minimal risk to participants. But if a trial is minimal risk, we can consider a waiver of consent or alteration of the consent process if traditional written consent affects the practicability of the trial. One focus of the Core’s work has been to study when a waiver or alteration of consent is appropriate in the various types of ePCTs. In addition, we explore what other methods could be used to advise patients that they’ve been enrolled in a research study, such as broadcast notification of the research placed in prominent locations, with contact information for questions.
From the inception of the Collaboratory, both the NIH and the Office for Human Research Protections (OHRP) have been involved in helping work through how to manage these issues in a way that respects individuals enrolled in a trial while also making it possible to conduct the trial without a lengthy informed consent process when it is not required under the regulations. We will continue to look at these issues with the new Demonstration Projects to get a better feel for emerging patterns. The Core has developed several publications addressing ethics and regulatory considerations for ePCTs, and we will continue to contribute to this growing body of knowledge to share with the larger research community.
What challenges lie ahead?
A big challenge is staying aware of how the regulatory framework may change during the course of the trial, and how those changes affect the conduct of a study. For example, the revised Common Rule impacted the way IRBs review research and investigators conduct their research. It’s also important to remember what we’ve learned as a research community—for example, we’re developing better ways of giving notice to patients that they’re enrolled in a trial. And the challenge in part is that studies have used different methods of notification with varying success, and so we need a way to compile that information into an accessible format to help future study teams decide how to apply those learnings to their study.
Our challenge is to build the grammar, the framework, and the thinking process for ethics and regulatory issues in pragmatic trials. Having resources like the Living Textbook available is helpful for researchers, providing insight into how others are framing these issues and conducting their trials.
Any words of advice for new ePCT investigators?
Sort out what part of the trial is research and what part is clinical care. This is essential for study teams to define so that they know what parts of the trial are subject to the federal regulations. It’s important to segment out and treat the clinical part of the study as clinical care. Within the research part, evaluate how the regulations apply. Think carefully about your trial and work through all the pragmatic pieces, for example:
What access to the electronic health record will you need?
How will you recruit participants?
If consent is required, how will you consent participants?
One of the strengths of the Core is that we’re able to work with study teams while they’re still finalizing the design of the trial, and together build on each others’ experiences, focus on specific issues, and in some cases, change their approach in order to make the study work better in the healthcare setting or with potentially large numbers of enrollees. I think the best resource for new investigators is meeting other researchers who have done this work and hear how they addressed and overcame challenges.
The Coordinating Center of the National Institutes of Health (NIH) Health Care Systems Research Collaboratory is supported by the NIH Common Fund through a cooperative agreement from the Office of Strategic Coordination within the Office of the NIH Director. Read more about the Ethics and Regulatory Core in the Living Textbook, and learn more about the NIH Collaboratory's other Core Working Groups.
Robert J. Mentz, MD, FACC, FAHA, FHFSA
Director, Duke Cooperative Cardiovascular Society
Associate Program Director, Duke Cardiovascular Disease Fellowship
Duke University Medical Center and Duke Clinical Research Institute
Good Clinical Practice Guidance and Pragmatic Trials: Balancing the Best of Both Worlds in the Learning Health System
International Council for Harmonization (ICH); Good clinical practice (GCP); Learning health system; Pragmatic clinical trials; Institutional review board (IRB); Research oversight; Regulatory issues; Quality by design (QbD)
Good clinical practice (GCP) guidance details the responsibilities, procedures, and recording that are necessary for appropriate trial conduct; for example, conducting the trial in accordance with an IRB-approved protocol with appropriate adverse event monitoring and reporting.
There is an urgent need to streamline randomized trials. Key obstacles are lack of transparency, lack of representativeness, and lack of evidence of competence.
In the United States, clinical investigators must abide by guidance from FDA, HHS, and ICH-GCP. Yet it is hard for investigators to keep track and to know how GCP applies to their study.
GCP as an overall construct is useful, but it does not deal well with issues particular to pragmatic trials or trials outside the FDA-regulated world.
With embedded pragmatic trials, informed consent is more nuanced. New considerations and approaches for consent have arisen since ICH GCP first came into effect.
Establishing quality by design will take time, effort, and educating IRBs to understand how QbD can be used to avoid errors in a trial and collect data that is fit-for-purpose.
It’s crucial that trials address an important question, answer that question reliably, and keep participants safe.
A new perspective article by NIH Collaboratory investigators describes the unique, unexpected challenges researchers face when clinical practice guidelines and policies change during the conduct of a pragmatic clinical trial (PCT). The article was published online this week in Clinical Trials.
The NIH Collaboratory Demonstration Projects are PCTs that test interventions to address urgent public health problems. They involve hundreds to thousands of participants and generally include usual care as a control arm. During the course of these years-long trials, clinical practice guidelines and policies changed due to new evidence from observational studies, small trials, and shifting expert opinion. Such changes can have profound effects on usual care and, therefore, threaten the ability of the PCTs to address the questions they were designed to answer. Investigators must strike a balance between the primary ethical obligation to protect patients by adhering to new best-practice guidelines and policy and the secondary, yet crucial, obligation to develop high-quality evidence to improve care.
“PCTs are an important means of producing high-quality evidence needed to better inform clinical practice. However, when guidelines or reimbursement policies change during the conduct of a PCT, the ethical obligation to gather information to develop evidence-based practices may conflict with the primary ethical obligation to participants.” — Curtis et al, Clinical Trials, 2019
Based on their aggregate experience with the NIH Collaboratory, the authors provide broad recommendations and strategies for overcoming these challenges, including protecting the well-being of patients; involving stakeholders, health system leaders, and the entity charged with data and safety monitoring; and actively monitoring changes and site-level responses to them. If changes to the standard of care are merited, investigators should provide equal opportunity and support for the recommended changes. Finally, during the design phase, investigators should communicate with the entities charged with creating guidelines to see what is needed and to anticipate possible future changes.
“The ability to appropriately address the tension between modifications to clinical guidelines and the need to generate quality evidence to support those guidelines is a crucial consideration for the fulfilment of a learning health system.” — Curtis et al, Clinical Trials, 2019
The Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare and Medicaid (CMS) have announced a proposed rule intended to advance interoperability and support the access, exchange, and use of electronic health information. Notably, the rule would require that patients have the ability to electronically access their health information at no cost.
The rule also proposes a United States Core Data for Interoperability (USCDI) standard, which, if adopted, would add data beyond those included in the current common clinical data model to support nationwide interoperability of CMS data. Specifically, clinical notes, data provenance, pediatric vital signs, patient address and phone number (to support data matching) will be added if the measures are adopted.
“Today’s announcement builds on CMS’ efforts to create a more interoperable healthcare system, which improves patient access, seamless data exchange, and enhanced care coordination,” — CMS Administrator Seema Verma, from the NPRM Press Release
Real-world data: routinely collected information about a person’s health status in the electronic health record, claims, registries, and other sources, including patient-generated sources.
Real-world evidence: reliable, clinical information derived from real-world data about risks, benefits, and burdens of therapies.
This framework will apply to various pragmatic clinical trials embedded in health care systems and conducted as part of routine care (and will not apply to more traditional clinical trials conducted parallel to care).
Three main considerations are included in the framework:
Will the real-world data be fit for use (do they reliably and adequately represent the concept)?
Will the evidence generated by the trial provide adequate evidence to help answer regulatory questions?
Will the conduct of the study meet FDA regulatory requirements?
The Food and Drug Administration (FDA) is proposing a rule to allow for a waiver or alteration of informed consent for clinical investigations posing no more than minimal risk to human participants. This rule would align FDA regulations with the Common Rule, reduce burden and costs for Institutional Review Boards, and be expected to lead to advances in healthcare.
“We expect benefits in the form of healthcare advances from minimal risk clinical investigations and from harmonization of FDA’s informed consent regulations with the Common Rule’s provision for waiver of informed consent for certain minimal risk research.” — Federal Register /Vol. 83, No. 221
Currently, FDA allows a waiver or alteration of consent only in life-threatening situations. If aligned with the Common Rule, a waiver or alteration would be allowed if the IRB finds and documents that 1) the research involves no more than minimal risk, 2) the rights and welfare of subjects will not be adversely affected, 3) the research could not practicably be carried out without a waiver, and 4) the participants will be provided with additional pertinent information after completion of the trial.
The NIH Collaboratory recently convened a workshop to explore embedded pragmatic clinical trials comparing two or more therapeutic medical interventions. These “A vs B” trials are meant to test existing, viable treatment alternatives where there is uncertainty about which treatment is best in which populations. There are unique barriers that make these types of pragmatic trials especially challenging to implement. For the workshop, a panel of experts gathered to discuss challenges and solutions regarding partnering with healthcare systems to conduct the trials, unique legal and ethical issues, and design and operational considerations. The summary of the workshop is now available: Workshop Summary: Embedded Pragmatic Clinical Trials of Therapeutic A vs. B Interventions
Embedded pragmatic clinical trials of therapeutic A vs. B interventions workshop videocast.
Renee Mitchell, MT(ASCP), CLS(NCA)
Boston Scientific Corporation, Inc.
Terrie Reed, MSIE
Senior Advisor for UDI Adoption
U.S. Food and Drug Administration (FDA)
Roseann White, MA
Director of Innovative Clinical Trial Statistics
Duke Clinical Research Institute
MDEpiNet RAPID and SPEED Projects: Leveraging Real World Evidence to Get Better, Faster, Cheaper Medical Devices for Physicians and Patients
Medical devices; Real-world evidence; Medical Device Epidemiology Network; MDEpiNet; Unique device identifier; UDI
In partnership, clinicians, device developers, and FDA can benefit from the use of real-world evidence on medical devices:
Clinicians can contribute to the generation of real-world evidence.
Device manufacturers can use real-world evidence to evaluate and release new devices and expand indications.
Regulatory bodies can increase the use of patient-level data for device approval.
Unique device identifiers (UDIs) make it possible to follow medical devices longitudinally, advancing the quality of real-world evidence and allowing more sophisticated analyses.
The vision for the future is that registries will transform into big data solutions using multiple sources and will be more robustly integrated with electronic health records (EHRs). Both EHRs and registries will play a role.
More organizations as partners brings greater diversity, advancing better data and results. When stakeholders work together, learning curves can be accelerated toward a transformational approach to real-world evidence.
Meeting minutes and supplementary materials are available that summarize discussions related to the ethics and regulatory issues associated with each of the new UG3 Demonstration Projects. These discussions, which took place by teleconference, included representation from study principal investigators and study teams, members of the NIH Collaboratory Ethics and Regulatory Core, NIH staff, and NIH Collaboratory Coordinating Center personnel as well as some IRBs responsible for oversight of the projects.