Care at the End of LifeInstitute of Medicine
2004
[[Introductions]]
This session will focus on regulatory and ethical issues in children’s health services research, with particular emphasis on practical considerations.
By way of audience assessment, how many of you have gone through Institutional Review Board review of a protocol? How many have done so for a project involving children? Has anyone served on an IRB? Has anyone had first hand experience with HIPAA requirements related to research?
I’m going to talk about the special regulatory protections that apply to research that includes children and I will discuss some recommendations in a recent Inst of Med report. The IOM is the health policy arm of the Natl Acad of Sciences, a private nonprofit organization that was chartered by Congress in 1863 to provide independent expert advice on scientific matters.
IOM
Responsible Research (2003)
View or purchase at www.nap.edu
The report on The Ethical Conduct of Clinical Research Involving Children builds on an earlier, broader report on improving the system for the responsible conduct of biomedical research.
I should also mention another recent Academy study on research protections in the social and behavioral sciences. A major conclusion of that study, relevant to much health services research, is that the application of federal regulations needs to be calibrated to the level of risk presented by research. Also fed agencies should provide clearer guidance to investigators and IRBs about how to assess social and beh research that falls outside the biomedical arena that has been the main focus of efforts to develop ethical principles and reg standards for human research.
IOM
2002 Best Pharmaceuticals for Children
2003 Pediatric Research Equity Act
1997 to 2001: Estimated tripling of children participating in clinical trials
Underscores importance of research protections for children
In recent years, Congress and government agencies have adopted policies to expand the amount of public and private research, especially, drug research, that includes children. Some policies involve incentives (granting extra patent protection time for companies that do studies to support pediatric labeling of drugs) and others involve NIH or FDA requirements that pediatric research be conducted when feasible and relevant.
We don’t know the total numbers but just from 1997 to 2001, it has been estimated that the number of children participating in industry sponsored clinical trials tripled.
This underscores the importance of special research protections for children, who are vulnerable because they usually lack the maturity and legal capacity to provide informed consent to research participation.
IOM
CHARGE TO IOM COMMITTEE
Consider definition of minimal risk for purposes of approving research involving children
Assess appropriateness of regulations for children of different ages
Evaluate regulatory compliance
Consider IRB roles, responsibilities
This slide and the next briefly summarize the tasks for the IOM study that were specified in the Best Pharmaceuticals for Children Act of 2002. A key purpose of this legislation was to renew financial incentives for drug companies to do studies to develop labeling information on the safe use of a drug with infants, children, and adolescents.
[[Read through next two slides]]
IOM
CHARGE (cont’d)
Examine comprehension of parents and children of child’s research participation
Examine process for obtaining parental permission and child assent to research participation
Examine appropriateness of payments to parents or children
[[Read through]]
Common Rule (Subpart A): basic regulations to protect human research participants; developed by DHHS; now applies to 17 agencies
Subpart D: protections for children; also adopted by Dept of Education, CIA, and SSA but not, e.g., HUD, EPA, etc.
FDA: similar but separate regulations
The general federal regulations on human research protections—what are called Subpart A or the Common Rule—now apply to 17 major agencies. Within DHHS, Subpart A applies to government conducted, supported, or regulated research, although some research institutions apply the regulations to all research regardless of source of funding or regulatory status.
In contrast, the protections for children—what are called Subpart D—only apply to DHHS, Dept of Educ, and—oddly—the CIA and Soc Sec Admin.
FDA has similar but separate regulations to those governing DHHS supported or conducted studies.
IOM
REGULATORY FRAMEWORK
Some research that can be approved for adults cannot be approved for children
If research with children involves more than minimal risk, it must (in brief summary)
involve only slightly more risk AND children with disorder/condition AND vitally important have potential for direct benefit OR
knowledge about the disorder/condition OR
be approved by DHHS or FDA (rarely)
It is important to understand that standards set by Subpart D mean that some research that can be approved for adults cannot be approved for children.
In very abbreviated summary, research with children can be approved
---if it involves no more than minimal risk OR
---if it involves children with a disorder/condition AND only a minor increase over minimal risk AND the potential for vital knowledge about the d/o/c OR
---if it has the potential for directly benefiting participants and meets certain other conditions OR
--if it is referred to and approved by the Secretary of DHHS or Commissioner of the FDA
IOM
Definition in Subpart A:
probability and magnitude of harm or discomfort anticipated in research are not greater . . . than those ordinarily encountered in daily life or . . . [in] routine physical or psychological examinations or tests.
Evaluating and categorizing risks in research are among the most challenging tasks for IRBs. We found many reports of considerable variation in how IRBs evaluate the same research protocol. E.g., 6 of 9 IRBs finding that a CF study involved only a minor increase over minimal risk but 3 saying there was more than a minor increase. Or 2 IRBs concluding that a test of diluted smallpox vaccine with kids met the criteria for IRB approval but 1 concluding that only the Secty of DHHS could approve it.
Subpart A of the Federal regulations defines minimal risk to mean that the
[[Read the definition]]
DEFINITION: Minimal Risk
Interpretation: What is minimal risk is same for healthy and ill children
It is not acceptable to approve higher risk in research because children to be studied research face higher risk in their daily lives (e.g., unsafe homes) or in their medical care (e.g., painful tests or treatments)
Getting to the basics, the IOM report says that the definition of minimal risk should be the same for healthy, average children and children who are ill or in risky situations.
That is, IRBs should not change the threshold of minimal risk simply because the children to be studied face higher risk in their daily lives (e.g., unsafe homes) or in their medical care (e.g., painful or dangerous tests or treatments).
The regulations do allow children who have a disorder or condition to be exposed to a slight increment in risk if the research could generate vital knowledge and meets certain other conditions. We interpreted disorder or condition to include not just diseases but also certain social or environmental situations (e.g., exposure to certain health hazards) linked to health problems.
IOM
APPROPRIATENESS OF REGULATIONS: Recommendations
All research with children should occur under umbrella of formal human research participants program that incorporates the protections of Subpart D.
FDA rules should be consistent with other DHHS rules allowing waiver of parental permission when
Permission not in child’s best interests
Other safeguards in place
The report concluded that the regulations were generally appropriate for children of different ages. It also concluded that changes in the regulations themselves are not likely to reduce the variability in interpretation that so frustrates investigators, research sponsors, and others. The IOM recommends only two regulatory changes
[[read the slide]]
We recognized that there are questions about whether the federal government can extend research protections beyond federally supported or regulated research. So we also encouraged state and voluntary action to do so.
IOM
Lack of data—especially on research involving children—make systematic evaluation impossible.
Considerable evidence of inconsistency in interpretation.
Some evidence of inattention to certain aspects of regulations.
With respect to compliance, the committee found
--insufficient data to really assess extent of compliance
--considerable evidence of inconsistency in interpretation of the regulations
--some indications of inattention to certain criteria in the regulations—for example, nothing in IRB minutes to indicate that they considered all the requirements for approving research involving children.
IOM
COMPLIANCE WITH REGULATIONS: Recommendations
Need for more explicit federal guidance to investigators and IRBs to encourage consistency and compliance with Subpart D
Guidance should be easily located on federal & IRB web sites
OHRP, FDA should collect more data to guide education, QI, enforcement
With respect to compliance, the committee made these recommendations.
[[read the slides]]
Findings
Adults—as parents and in their own right—often misunderstand research
Therapeutic misconception: believing purpose of clinical research is to treat rather than gain knowledge
Written information is too complex
Focus is too often on forms not communication
Although research on parents specifically is rather limited, the committee concluded that research is reasonably consistent that adults, including parents, often misunderstand research.
In particular, they often misunderstand the purpose of research—not adequately appreciating that the primary purpose of research is to gain knowledge rather than to provide clinical care.
Evidence is plentiful that written information—including informed consent documents—are too complex for most people.
Also, the focus of investigators and IRBs is too often on these consent forms rather than on the process of communication to help people understand the possible harms and benefits of being in research and make informed choices.
IOM
COMPREHENSION OF RESEARCH: Findings
Even young children can understand basic information about what will happen in research.
Older adolescents similar to adults in many aspects of understanding.
Education and discussion usually increase understanding.
Again, research is limited but it indicates that
[[read the slides]]
Children, when appropriate, provide their assent (or dissent)
Just to review the language of research ethics, adults can only provide informed consent for themselves.
They provide permission for involvement of their children in research.
Children, when appropriate, provide their assent—or dissent.
IOM
Seeking assent is respectful.
My daughter will be nine years old and she needs some kind of input in what’s going on. She’s presently in a study and I need for her to be able to understand what she’s getting herself into . . . She’s at the point where she asks a lot of questions.
Andrell Vaughn, parent, 2003
Assent should not be judged by the same standards as informed consent, especially for younger children. It shows respect and it does provide information consistent with a child’s intellectual and emotional maturity.
This quote shows how a mother we met with understands what her child needs.
IOM
Focus on process not forms
It has to be very interactive process. After I was asked this entire list of questions, I began to question my own first response. Just giving a kid a piece of paper--no matter how comprehensible--is not effective. I think the kid needs to be prompted with questions.
Sarah, research participant at age 13
Many groups have urged that researchers and IRBs focus less on forms and more on process.
This quote shows how an adolescent we met with perceived the benefits of a real discussion.
IOM
PERMISSION AND ASSENT: Recommendations
Provide details in protocol on how permission and assent will be sought.
Try to provide written information at 6th grade reading level.
Devise ongoing process for families facing serious, acute illness.
To direct attention to the process of seeking permission and assent, the committee recommended that research protocols be expected to provide details—who, what, when, where, and how often.
Also, make written information easier to understand—at the 6th grade level if possible.
And think of permission and assent as ongoing process not a one-time event for families facing serious, acute illness.
IOM
Permission as ongoing process
There is never enough time in those situations to make an “informed decision.” We signed [the form] because that’s what you do.
It’s always at the worst time to be reading this type of material . . . Parents aren’t in control nor is the child.
Joseph Lilly, parent, 2003
Again, a parent we met with summarized the difficulties parents face when they have just learned that a child is in serious jeopardy.
So, we encourage the design of a process that goes along with parents’ evolving understanding of their child’s situation and that also takes changes in the child’s condition into account.
Also recommended more research on comprehension as well as process of communication related to permission and assent
IOM
PAYMENTS TO PARENTS OR CHILDREN
Concern: some payments may distort parent’s or child’s decisions and lead to choices that are not in the child’s best interests.
Findings: limited data but evidence of considerable variability in practices
Findings: lack of explicit IRB policies and guidance for investigators
On payments to parents or children, the concern is that
[[read the slide]]
IRBs should adopt explicit policies on acceptable payment practices.
To equalize access to research participation, IRBs, agencies, sponsors should encourage investigators to accommodate parental work and family commitments.
The committee again recommended that IRBs adopt explicit policies—in advance of making decisions about specific research protocols.
Also, beyond payments, the committee recommended that researchers try to equalize access to research by accommodating parents work and family responsibilities
For example, have evening times for research visits.
IOM
Okay: reasonable reimbursement for expenses of being in research
Okay: tokens of appreciation
Scrutinize carefully: payments for child’s time and inconvenience for research w/o prospect of benefit
Never okay: payments to parent or child for increased research risk
Finally, the committee agreed that it is appropriate to reimburse expenses incurred due to research participation.
Truly token gifts of appreciation are also acceptable.
Payments for a child’s time or inconvenience are permissible but should be scrutinized carefully for the potential to distort decisions.
And it is never okay to pay parents or children’s based on how risky the research is.
Now, turn the session over to Angela.