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Australasian Human Research Ethics Consultancy Services Pty Ltd (AHRECS)

When Research is the treatment: why the research/clinical care divide doesn’t always work0

 

Nik Zeps
AHRECS Consultant

Health services are often operated by people who strive to improve the way they deliver care. In the public imagination improvements arise from ‘breakthroughs’ such as the discovery of new disease mechanisms and drugs or devices to address these. However, it is not just novel treatments that lead to better outcomes. Sadly, it is not widely recognised that eliminating sub-optimal practices or variations in healthcare practices play a major role in improving clinical outcomes. Indeed, I don’t recall a headline announcing an increase in operational efficiency in any health service as this is hardly exciting news regardless of its value. Funders of healthcare are interested though, and in a report entitled Exploring HealthCare Variation in Australia: Analyses resulting from an OECD Study, published by the Australian Commission on Safety and Quality in Health Care in 2014, the authors stated that:

Unwarranted variation may also mean that scarce health resources are not being put to best use. As countries face increasing pressure on health budgets, there is growing interest in reducing unwarranted variation in order to improve equity of access to appropriate services, the health outcomes of populations, and the value derived from investment in health care.

All consumers of health care should therefore be interested in this and support those working toward improving health services. Unfortunately doing this work is difficult and often unrewarding. The ethical imperative to do this work is also often thwarted by the ‘ethics’ and governance framework that too often encumbers those doing it {Clay-Williams, 2018 #516}. It is also largely left to the NHMRC to fund Health Services Research (HSR) and the Comparative Effectiveness Research (CER) studies that generate evidence to reduce wasteful practice. In contrast, very little funding from health services themselves go to these activities despite them being the direct beneficiaries of the research.[1] Importantly, those engaged in HSR and CER are becoming an increasingly larger proportion of the total medical research endeavour in Australia, and by classification constituted almost one third of NHMRC competitive funding in 2019[2]. This is despite the fact that the studies undertaken often take several years to complete and therefore the number of publications is smaller than for life sciences. For HSR, publication is rarely in the ‘higher impact’ journals, whereas for some CER Trials the outcomes are so profound that they are of international significance and will be published in widely read international journals. Pleasingly this suggests that the criteria for assessment do not necessarily disadvantage such research in terms of competitiveness for funding, but also reflects the fact that clinical trial funding from the NHMRC supports a great deal of CER studies.

Those doing HSR and CER are also often involved in working in health services as clinicians which reduces the amount of time they can devote to academic research and to build a competitive personal research portfolio. The NHMRC has implemented a “Relative to opportunity” process in an attempt to address the almost impossible task of taking into account personal circumstances, but I doubt anyone is truly comfortable in applying it across the breadth of candidates and disciplines. Indeed, it could be argued that it is a surprisingly unscientific and subjective approach to use in schemes that are rewarding the quality of scientific approaches to address major societal issues. In 2019, only 7% of investigator grants went to applicants identified as HSR researchers.

It is difficult to think of what could replace this system across all areas of scientific endeavour but there is a possibility of rethinking how we fund and manage HSR and CER clinical trials. In both types of activity the end points are focussed on providing evidence to inform changes to clinical practice and health service delivery. As such the end users are health care providers and their funders. It would therefore seem much more appropriate that the end users play a much greater role in judging what kind of research should be done as well as the value of the outcomes of existing projects. The problem with this is that Health Services do not have the internal infrastructure and capability to manage research and have no incentive or means to do so.

What is particularly important to reflect on here is that publication metrics and university-based career milestones are largely irrelevant to the health services and arguably should not be the drivers of why the work is done. It would be more appropriate to have a regular employment relationship between the health services researchers and the health services in a manner that does not differ to clinical safety and quality activities. Sadly, health services have not seen the need to invest in this out of their operating budget and one can see why they would not if universities will do so. The problem though is that health service managers inevitably regard them as academic exercises with no direct relevance to routine health practice and when budgets are tight any support rapidly evaporates.

Like other industries that are reliant on R&D, it could be argued that a defined proportion of all health funding should go to HSR and CER that is conducted and run within the health services themselves. In the UK the National Institute for Health Research (NIHR) was established in 2016 with £1 billion to do just this, representing just under 1% of the total National Health Service Budget at the time (£126 billion[3]). The current public expenditure on health in Australia is $81.8 billion AUD, however, the total health spend, including private and personal (out of pocket) expenditure was $185 billion in 2017/2018[4]. The combined NHMRC and MRFF expenditure on all HSR and clinical research is estimated to be around $800million in 2019, less than 0.5% of the total health expenditure. The difference with the UK is that the Australian funding is largely administered through universities and not by the health services as in the UK.

I would propose that researchers engaged in HSR and CER should be employed by the health services themselves and be regarded as intrinsic to the operations of the health service. In addition, I propose that these staff would not publish papers under their own names but instead publish under the health service banners, either singly or as collaborations of organisations. In this way individual career progression would be based upon demonstration of outcomes in the same way that other activities in the health service are evaluated. Staff who do their job well would continue in their employment and be eligible for ongoing employment. Career progression would be through building a demonstrated portfolio of achievement that is attested to by their employers in a similar way that professional references are provided. Success for individuals would therefore be entirely based on being able to show how they had contributed to productive activity within the organisation.

If this major change to operating this type of research was made then it might also change one of the other major barriers that currently exists, the disproportionately burdensome ethical and governance requirements for such ‘research’ which is mostly treated as having the same risk profile as novel interventional studies. The aims of research are stated to differ from those of providing clinical care to patients, and this is at the heart of the Declaration of Helsinki’s ethical principles as well as those known as The Belmont Report published in 1979. In the Australian National Statement on Ethical Conduct in Human Research, such a distinction between clinical care and research is no longer identified and not commented on so explicitly.

For HSR and CER the distinction between what is routine practice and what is research is extremely blurred, particularly within the context of a self-improving/self-learning healthcare system in which a constant cycle of analysis of the current status of clinical activity informs the delivery of healthcare into the future. The robust methodologies employed to do the analysis and to test potential alternative practices aimed at improving care are indistinguishable to those used for researching novel and potentially more risky interventions. However, the risk profile is completely different, particularly where the research involves one or more practices already in widespread use. A more embedded framework that ensures that ethical issues are addressed at a systemic level rather than through the existing ethics and governance system that treats such work as ‘other’ is needed. The 2019 draft Clinical Trial Governance Framework developed by the ACSQHC goes some way toward creating a culture in which this can be delivered although it will likely require significant cultural change at most health services engaged in research.

We need a system that values those doing this work as core employees and is directly vested in the outcomes of the work and their implementation into improved practice as the prime demonstration of productivity. Such a cultural change will provide the drive to streamline the overly burdensome regulatory framework that currently exists. Such a framework would deliver its own efficiency dividends in a positive cycle enabling more of this work to be done and an acceleration in avoiding wasteful practice and generation of data that brings real improvements to people’s lives. It would seem that this is the very definition of an ethical outcome.

[1] ACSQHC/ACTA report on clinical trial benefits https://www.safetyandquality.gov.au/publications-and-resources/resource-library/economic-evaluation-investigator-initiated-clinical-trials-conducted-networks-final-report

[2] https://www.nhmrc.gov.au/file/14808/download?token=GAkwLHj0

[3] https://fullfact.org/health/spending-english-nhs/

[4] https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-australia-2017-18/contents/summary

This post may be cited as:

Zeps, N. (04 June 2020) HWhen Research is the treatment: why the research/clinical care divide doesn’t always work Research Ethics Monthly. Retrieved from: https://ahrecs.com/human-research-ethics/when-research-is-the-treatment-why-the-research-clinical-care-divide-doesnt-always-work

COVID 19, human research and human research ethics review1

 

Prof. Colin Thomson AM
AHRECS Senior Consultant

We at AHRECS, like all our friends, colleagues and clients, are becoming more and more aware of the immediate and probably long-lasting impact of this pandemic on almost every part of our lives. It has compelled researchers to vary methodologies adopted for both ongoing and planned human research. It has also been forcing institutions to adapt human research ethics review processes to enable responsible social distancing.

In this brief item, we are opening a conversation to offer assistance, ideas, successes and strategies to achieve these changes while maintaining the ethics and quality of human research and ethics review.
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Human research ethics review

A number of our clients have long been conducting ethics review meetings online because of geographical necessity. Australia’s regional universities have led these innovations and acquired considerable experience in managing to achieve effective, efficient and quality ethics review. They use different online platforms and have experience of the strengths and weaknesses of several of these in running both synchronous meetings and asynchronous review processes.

They also have experience of assisting those committee members who have been reluctant to review digital applications. The current crisis may compel further limitations on such assistance; for instance, institutions may be unable to print and dispatch agenda papers and members may be less willing to receive them. Experience in enabling less IT-savvy members to adopt online processes with comfort could be a value now to other institutions making these changes.

There may also be substantive issues in addition to these ones of process.  For example, how does COVID-19 change our perceptions of merit; what if it shifts the balance in an unfavourable direction after a project has been approved?

We have asked some of our clients who have these experiences to respond to this item and encourage others to either offer or seek assistance, not necessarily through AHRECS, but directly. This may be the time in which the development of broader community of human research ethics review practice will be more needed than ever.
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Human research

For researchers, particularly those with approved projects that involve interaction with participants, the new restrictions on physical distancing and self-isolation are likely to present significant difficulties in continuing and completing their projects. They will need to change the manner of that interaction and the ways they collect the data they need so as to limit risks to participants and to themselves.

In normal circumstances, such changes would require prior ethics approval to conform to the conditions of approval that the National Statement requires (National Statement 5.5.6 (c)). However, the consequences for researchers of seeking prior approval may have a greater impact on the continuity and completion of their work and, in busy research institutions, lead to a significant workload increase in approval requests for urgent project variations.  In addition, those alterations to data collection will involve, in due course, changes in the manner in which data are stored, used and either retained or destroyed, all of which would, in normal circumstances, require consent from participants.

Other issues that researchers may face include:

  1. Identifying and fulfilling the responsibilities that arise when they have to close down their research, e.g. can they use data already collected? Do they inform participants and, if so, how?
  2. What obligations they may have to participants who are distressed by the current situation, especially when relevant to the research, as it is entirely foreseeable?
  3. How do they continue to engage in consultations to which they are committed, whether with communities or with all stakeholders?

In the situation that now presents itself, new strategies will need to be devised and it is likely these will depend more than ever on the ethics reviewers’ trust of researchers. For example, an institution could permit researchers to make urgent changes themselves to data collection methods in order to protect participants and meet COVID-19 limitations on condition that they notify the ethics reviewers as soon as practicable following the implementation of the change. That later application could also include a request for approval of changes to data use, management and retention or destruction.
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Guidance for researchers

Australian governments at Commonwealth, State and Territory level have provided combined guidance for researchers, especially those conducting clinical trials and other institutions have combined to offer practical advice for researchers on how to negotiate needed changes and ethics review.
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Research about COVID-19

The COVID-19 situation will generate research initiatives, not only in relation to the immediate medical needs such as vaccines, but also about the impact on health professionals, researchers, and families of those victims of infection, serious illness or death, as well as about the social impact of information, social distancing and self-isolation.

In vaccine projects, issues of justice in inclusion of participants are likely to be difficult to resolve: should all be included or only those capable of a voluntary consent.  And achieving an ethically sound consent will be complicated by the need to provide sufficient information, counter the possibility of social pressure to participate or the heightened influence of health professionals.  As Haaser says, “It is not easy to say no to a hero.”
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An invitation

In this brief note, these are but early suggestions. We invite our readers to respond to these thoughts with ideas and experience of strategies that they, as researchers or ethics reviewers, have adopted to address the new needs.

Further, and more importantly, this invitation is to encourage institutions, ethics review administrators, ethics review committees and researchers to exchange their ideas and their experiences.  It may be ironic that one of the effects of the COVID-19 crisis is to promote a wider community of good ethical human research practice – but it would nonetheless be a very good outcome.

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This post may be cited as:
Thomson, C. (18 April 2020) COVID 19, human research and human research ethics review Research Ethics Monthly. Retrieved from: https://ahrecs.com/human-research-ethics/covid-19-human-research-and-human-research-ethics-review

Research ethics review during a time of pandemic0

 

Gary Allen, Mark Israel and Colin Thomson

COVID-19 is prompting changes to academic delivery, essentially intended to contain the spread of the virus and protect the most vulnerable from its effects. As more countries introduce travel restrictions and mandate self-isolation, it will no doubt change the way we conduct research.

Research ethics review needs to adapt to meet the needs of these trying times.

We have written previously about the use of proportional review and proportional processes to progress matters outside of a research ethics committee meeting.

But there will always be matters that need to be considered by a human research ethics committee.

One of the strengths of committee review and one of the reasons flying minutes are not favoured is that a committee’s membership brings together different perspectives, lived experience and knowledge.

It remains important that committees exercise their responsibilities in paragraph 5.2.31 of the National Statement.

5.2.31 Decisions by an HREC about whether a research proposal meets the requirements of this National Statement must be informed by an exchange of opinions from each of those who constitute the minimum membership (see paragraph 5.1.30). This exchange should, ideally, take place at a meeting with all those members present.

But, that does not mean committee members need to sit together in a room.  The same valuable results might be achieved with video conferencing packages like Zoom and MS Teams, Blackboard Collaborate, perhaps even aided by asynchronous online collaborations on feedback. AHRECS has worked with many institutions that already run their meetings successfully online.

Of course, institutions may need to assess their on-line or virtual meeting systems to ensure they enable chairs to be satisfied that there has been an exchange of opinion and not merely individual expressions that are unseen by other members.

In addition, AHRECS can help you take advantage of an online meeting by conducting a short professional development activity on a topic of your choice.  This would involve a further reading and reflection booklet, 15-minute pre-recorded presentation (e.g. Social Media and human research ethics) and 15 minutes of Q&A/discussion.  The cost of such an activity is A$900.

Email enquiry@ahrecs.com to discuss further.

 

Lost time may never be found again but is it time to talk about the duration of ethics approvals?0

 

“To everything there is a season, and a time to every purpose” a time to report on ethical conduct, a time to renew an approval, or a time to face misconduct proceedings.

Dr Gary Allen

What is the length of ethics approvals that your HREC grants?  In this article, I will discuss this question and some of the reasons for choosing approval periods.

A related question is, under what circumstances should an ethics approval be withdrawn?  Can/should research ethics review bodies withdraw approval because of extended/repeated failure by a researcher to provide an ethical conduct report?

Australia is unlike the US where the conventional interpretation of the Common Rule is that ethics approvals are of one year.  Accordingly, US researchers must provide annual ethical conduct reports to maintain ethics approval and avoid needing to make a fresh application.

In Australia, the duration of approval is not specified by the National Statement and the only clear Australia-wide external requirement to provide reports in a certain time is paragraph 5.5.5 of the National Statement which provides that researchers should report to ethics review bodies at least annually.  As a result, approval duration is likely to be dictated by institutional policy and some have adopted maximum duration periods.  A short (e.g. 12 months) approval period and renewal requirement is one lever committees can use to compel researcher compliance to provide evidence that the needs for approval periods are being met.

There are, I suggest, four such needs that are served by a choice of duration of an ethics approval, namely:

  • Compelling a report from a researcher and allowing a review body to confirm that –
    1. a project is being conducted as per the approval, and
    2. the welfare and interests of participants are still being adequately provided for.
  • Providing an opportunity to reflect on any changes to national standards or institutional policies or pertinent cases that warrant a rethink of approvals.

Researchers can typically seek a long duration ethics approval because:

  • The design calls for repeated data collection across an extended period, such as a longitudinal ethnographic study;
  • The work is a component of a program of work focussed on a cure for a chronic condition; or
  • The work intends to compile an archive of biospecimens, data, document samples, audio-visual material or other items of historical/cultural significance.

The maximum duration of a research ethics approval would also appear to be connected to how long an HREC has operated and the amount of work the committee is undertaking. In Australia, institutional decisions on the matter can also be associated with changes in national ethics review requirements that occurred in 1999, 2007 and 2018 (and beyond).

Like other aspects of human research ethics practice in Australia, the approach to duration has reflected practice in the United States.  While Australia does not have the same kind of regulatory framework as the US where failing to maintain ethics approval can have consequences for institutions, the use of single year approvals is probably used as a way to promote adherence to the institution’s ethical conduct reporting requirement.

While understandable, such short-term approvals can punish conscientious researchers because of an institutional response to recalcitrant researchers.

However, early in a research ethics committee’s operation, it is not uncommon for it to grant approvals with durations of between one and three years.

This can reflect the committee’s confidence:

  1. in its role and decisions;
  2. and trust that researchers understand their responsibilities and will abide within the scope of the ethics approval; and
  3. that projects will progress as per applications or researchers will contact the institution’s research office if the unexpected occurs.

A low workload of a committee can serve as an incentive for short duration approvals and longer duration/longitudinal work is chunked out into two or more applications. Increasing the number of approvals may not allow the committee and research team to develop expertise before the committee commits to an extended period of research. Alternatively, a committee might be tempted to inflate its number of approvals artificially to attract either resources or credibility.

Conversely, when a research ethics committee is very busy, there may be more incentive to grant longer approvals to minimise the number of times the committee needs to review renewals of long duration projects.

Given, the National Statement (2007 updated 2018) is currently silent on the issue of the duration of ethics approvals, it might appear the Australian national framework should not impact on approvals. However, there is both a predictable impact and a real reason to rethink our current approach to the duration of approvals.

At this stage an update to Section 4 of the National Statement might be released in the next six months and an update to Section 5 will move out of the planning stage shortly.

Some institutions and committees tie the duration of ethics approvals and forced renewal around the timeframe during which the national arrangements might change (and perhaps inter alia institutional policy).  In Australia this might equate to around a five year approval duration.

The changed approach to updates to the National Statement means that such a cycle might not be especially helpful.

Suggested change to duration and monitoring procedures

We recommend institutions and HRECs do the following:

  1. Adopt a policy setting that the conduct of human research without prior ethics approval may be considered a breach of the Australian Code for the Responsible Conduct of Research (2018) and of the institution’s research integrity arrangements. This would be consistent with the Investigation good practice guide.
  2. Adopt a policy setting that any proposed change to a project must be submitted for prior review, otherwise the conduct of a project in a manner not in adherence to its ethics approval may be considered in breach of the Australian Code for the Responsible Conduct of Research (2018) and the institution’s research integrity arrangements.
  3. Adopt the practice of reminding researchers of their responsibility –
    1. to consider and safeguard the welfare of research participants
    2. to remain reflective of whether the risks of a project are justified by its benefits
    3. to remain reflective of the degree to which the project addresses the core ethical principles of the National Statement
    4. notify the HREC of any changes with regard to 3a-c.
    5. Notify the HREC if any participant raises a concern about the ethical design or conduct of a project. Including notifying the HREC if any participants withdraw consent because of a concern about ethical matters.
  4. Adopt a policy that a researcher who fails to meet the responsibilities described at 3 may be considered in breach of the Australian Code for the Responsible Conduct of Research (2018) and the institution’s research integrity arrangements.
  5. Adopt a policy that an ethics approval can be approved for the planned duration of a project.
  6. Adopt a policy that researchers must submit an ethical conduct report every 12 months during the currency of an ethics approval. Extended/repeated failure to do so may be considered a breach of the Australian Code for the Responsible Conduct of Research (2018) and the institution’s research integrity arrangements.
  7. Adopt a practice of timed reminders to researchers to provide overdue ethical conduct reports, culminating in breach proceedings[1].
  8. Adopt a policy and practice that every five years a clearance is active the research office/HREC assess whether there are circumstances that require a new ethics review of a project.

In most cases, a new review should not be required, but a standardised, clear checklist should be used to determine whether a new review is required. Subscribers to https://www.ahrecs.vip or https://www.patreon.com/ahrecs will find a suggested checklist for conducting such a check.

On this basis, I suggest research ethics review bodies/research offices can and should withdraw approval because of extended/repeated failure by a researcher to provide an ethical conduct report.  This however must be based upon documented policy and procedure.  It must also be foreshadowed in ethics approval notifications, report reminders and resource material.

[1] The approach here might be constrained by the research management system the institution is using.  This includes usefully tracking correspondence between the researchers and the research office.

This post may be cited as:
Allen, G. (3 March 2020) Lost time may never be found again but is it time to talk about the duration of ethics approvals?. Research Ethics Monthly. Retrieved from: https://ahrecs.com/human-research-ethics/lost-time-may-never-be-found-again-but-is-it-time-to-talk-about-the-duration-of-ethics-approvals

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