Transcript Basics of Clinical Research

Basics of Clinical
Research
Beth Elinoff, RN, MPH, CCRC
Human Immunology Research Coordinator
What is Clinical Research/
Human Subject Research?
Department of Health and Human Services
(DHHS) Definitions (45 CFR 46.102):
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1. Human Subject Research
In order for activities to be deemed “Human Subject
Research” by the DHHS, they must meet the definition
of “research” and involve one or more “human
subjects” as defined by DHHS regulations.
DHHS Definitions (con’t)
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A. Research
“A systematic investigation, including research
development, testing and evaluation, designed to
develop or contribute to generalizable knowledge.”
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Belmont Report Definition of Research
“Any activity designed to test a hypothesis, permit
conclusions to be drawn and thereby to develop or
contribute to generalizable knowledge (expressed, for
example, in theories, principles, and statements of
relationships).”
DHHS Definitions (con’t)
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B. Human Subjects:
“A living individual about whom an investigator
conducting research obtains (1) data through
intervention or interaction with the individual; or (2)
identifiable private information.”
DHHS Definitions (con’t)
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Intervention:
Includes both the physical procedures by which data
are gathered (eg. blood draw) and manipulations of the
subject or the subject’s environment that are performed
for research purposes
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Interaction:
Includes communication or interpersonal contact (eg.
questionnaires, interviews) between the investigator and
subject
DHHS Definitions (con’t)
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Private Information:
Includes information about behavior that occurs in a
context in which an individual can reasonably expect
that no observation or recording is taking place, and
information which has been provided for specific
purposes by an individual and which the individual can
reasonably expect will not be made public (eg. medical
record). Private information must be individually
identifiable (eg. the identity of the subject is or may
readily be ascertained by the investigator or associated
with the information).
Food and Drug Administration
(FDA) Definition of Human Subject
Research
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FDA has different definitions of “research” and
“human subjects”
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FDA guidelines must be followed when using a
drug or device in the study
History of Development of Human
Research Protections
1.
Public Health Service Syphilis Study ’32-’71
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Better known as the “Tuskeegee Syphilis Study”
Originally designed to make treatment available to
African-American men with syphilis, even though
there was no known effective treatment
Issues:
1.
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3.
Men were recruited without their consent
Misinformation about procedures, ie spinal taps
After penicillin was proven an effective treatment ’40’s),
men were denied antibiotics and prevented treatment
from military and local physicians
History of Development of Human
Research Protections
2.
US Food, Drug and Safety Act (1938)
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107 people died after taking sulfanilamide, a cold
remedy that contained anti-freeze.
This act enforces manufacturers to demonstrate
drug safety.
History of Development of Human
Research Protections
3.
Nuremberg Code (1947)
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Result of the trial of Nazi doctors and scientists
from WWII – no guidelines for human research
Guidelines:
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Need for informed consent
Research should be based on prior animal work
Risks should be justified by anticipated benefits
Only qualified scientists must conduct research
Physical and mental suffering must be avoided
No research where death/severe injury is expected
History of Development of Human
Research Protections
3.
Nuremberg Code (con’t)
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Problems:
1.
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3.
Little impact on research done in the US – thought to
condemn Nazis
No strength of the law behind it
Only applied to non-therapeutic human subject research
History of Development of Human
Research Protections
4.
Declaration of Helsinki (1964)
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Code of ethics developed by the World Medical
Association (now known and World Health Org)
Broader than Nuremberg Code
Geared towards therapeutic medical research
Recommended informed consent
Precursor to IRB requirement
Journals required all published research to follow
Declaration’s guidelines
History of Development of Human
Research Protections
5.
The National Research Act (1974)
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Culmination of hearings by US Congress
established the National Commission for the
Protection of Human Subjects of Biomedical and
Behavioral Research
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Purpose of The National Commission:
1. Identify basic ethical principles underlying the
conduct of human subject research
2. Develop guidelines to ensure conduct of human
subject research in accordance with those principles
History of Development of Human
Research Protections
5.
The National Research Act (con’t)
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45 CFR 46 – “Regulations for the Protection of
Human Subjects of Biomedical and Behavioral
Research”; Issued by the Department of Health,
Education and Welfare (later renamed DHHS)
Revisions made in late 1970’s and early 1980’s
By 1991, 16 other federal agencies/departments
applied 45 CFR 46 to research they fund/conduct
Referred to as the “Common Rule”
History of Development of Human
Research Protections
6.
The Belmont Report (1979)
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Issued by the National Commission for the
Protection of Human Subjects of Biomedical and
Behavioral Research
Purpose: resolve ethical problems that surround
the conduct of human subject research
One principle does not outweigh another; each has
equal weight
History of Development of Human
Research Protections
6.
The Belmont Report (con’t)
The three principles:
1.
Respect for Persons – treat people as autonomous
creatures and not a means to an end; provide extra
protection for those with limited autonomy
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Requires informed consent
Requires respect of privacy of research subjects
History of Development of Human
Research Protections
6.
The Belmont Report (con’t)
The three principles:
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Beneficence – minimize harm and maximize
benefit
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Requires use of the best possible research design to
maximize benefit and minimize harm
Requires researchers to be able to perform the
procedures and manage the risks
Prohibits research without a favorable risk-benefit ratio
History of Development of Human
Research Protections
6.
The Belmont Report (con’t)
The three principles:
3.
Justice – treat all people fairly and ensure burdens
and benefits are shared equitably
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Requires equitable selection of research subjects
Requires avoidance of exploitation of vulnerable
populations or populations of convenience (ie pregnant
women; children; incarcerated populations)
History of Development of Human
Research Protections
7.
International Conference on Harmonisation ICH (1990)
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Joint regulatory/industry project to improve
process of developing new products between
Japan, Europe and United States
Allows for international research studies to follow
same rules/regulations
Conference convenes to update regulations
Established “Good Clinical Practices”
Good Clinical Practices
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Known as GCP’s
Misnomer – they are rules/regulations for the
conduct of research
Sometimes called “Good Research Practices”
Standard for the design, conduct, performance,
monitoring, analyses and reporting of research
Even though established for drug studies, they
dictate appropriate conduct for all research
Innovative Practice vs. Research
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Innovative clinical practice is an intervention designed
solely to enhance the well-being of an individual patient
or client. The purpose is to provide diagnosis,
preventative treatment, or therapy to particular
individuals.
Considered “research” only if previous criteria is met.
At UPMC, the introduction of innovative procedures
or therapies into clinical practice (when research is not
involved), requires review by department chair and the
UPMC Technology Assessment Committee/Innovative
Practices Sub-Committee prior to implementation.
Quality Assurance vs. Research
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Precise definitions to permit the distinction between
research studies and quality assurance projects are
difficult and have not been established. In general, a
quality assurance project is a project that is focused
primarily on improving patient care within a given
patient care environment and, as such, the outcome
may not be generalizable to other patient care
environments.
Both UPMC and CHP require the submission of all
quality assurance projects for review.
Questions to distinguish QA from Research
(any yes response indicates research)
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Is there a commitment, in advance of data collection, to a
corrective plan given any one of a number of study outcomes?
Does the PI of the study have both clinical supervisory
responsibility and the authority to impose change?
Is the research being sponsored/funded by an external agency?
Does the proposed study involve the prospective assignment
of patients to different procedures or therapies based on a
predetermined plan?
Does the proposed study involve a “control group” in whom
the therapeutic or study intervention is intentionally withheld
to allow an assessment of its efficacy?
Questions to distinguish QA from Research
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Will the study intervention be delivered in a blinded fashion
wherein neither the physician nor the patient knows to whom
the study intervention or comparative intervention (eg.
standard care, placebo) was given?
Is the assessment of outcome blinded to the study intervention
for purpose of establishing the efficacy of the intervention?
Does the proposed study involve the prospective evaluation of
a drug, biologic or device that is not currently approved for
general use by the FDA?
Will patients involved in the proposed study be exposed to
additional risks or burdens beyond standard clinical practice in
order to make the results of the study generalizable?
Types of Study Designs
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Observational Designs
Types of Observational Studies
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Cohort Studies
A group of subjects followed over time
 Purpose: defining the incidence and investigating
potential causes of a condition (incidence)
 Can be prospective – investigator chooses a sample
group and measures characteristics in each subject
over a period of time that might predict outcomes
 Can be retrospective – same as prospective, except
all data collection and follow-up has happened in the
past; only possible if adequate data is available
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Types of Observational Studies
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Cross-Sectional Studies
Similar to cohort studies except all the
measurements are made at one time point with no
follow-up
 Purpose: describing variables and their distribution
patterns (prevalence)
 Strength – fast and inexpensive since there is no
follow-up or waiting time for outcome
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Types of Observational Studies
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Case-Control Studies
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Two groups of people examined for the same
outcome
Group 1 – “cases” or a population of people with a
certain disease
 Group 2 – “controls” or a population of people without
that same disease
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Purpose: compare prevalence of risk factor(s) in
subjects with the disease (cases) versus subjects
without the disease (controls)
Types of Study Designs
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Observational Designs
1.
Experimental Designs – interventional
studies
Experimental Studies
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These studies evaluate the effects of an
intervention
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Types of interventions:
Behavior modification (eg. a walking program to improve
weight loss)
 Drug (eg. a new investigational drug or studying a drug
for off-label use – subject to FDA regulations)
 Device (eg. a new investigational stent – subject to FDA
regulations)
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Strength: Can demonstrate causality
Phases of Experimental Studies
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Phase I:
Unblinded studies of a small number of healthy
volunteers to test safety of treatment (can sometimes
use people with the disease)
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Phase II:
Randomized studies of relatively small number of
people with the disease to test dose ranges and/or
efficacy of treatment
Phases of Experimental Studies
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Phase III:
Randomized studies of large number of people with
the disease to test efficacy of treatment on preselected outcomes
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Phase IV:
Large experimental studies or observational studies
conducted after treatment has been approved by the
FDA to assess performance of treatment (called
Post-Market Studies)
Do I really want to
conduct clinical
research?
What Help is Available?
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University of Pittsburgh IRB/RCCO
IRB Coordinators – wealth of knowledge; will
perform an informal review prior to official review
 www.irb.pitt.edu – IRB manual; required forms; link
to research training website; etc.
 Sponsored educational activities – monthly “Ask the
IRB” sessions; conferences on current issues; etc.
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Human Immunology Research Office
Human Immunology
Research Office
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Assistance with investigational human studies
involving transplantation that are initiated by
STI research or involves substantial support
from STI research
Act as repository for all documents related to
above studies and all other studies requiring
STI research participation (eg. Processing of
blood samples on 15th floor BST
Human Immunology
Research Office
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Services Available:
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Consultation regarding clinical aspects/logistics of
new projects
IRB summary protocol and consent form
preparation assistance
Project coordination:
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Assist with recruitment based on project
Ensure proper handling of samples/specimens from
patient to lab
Human Immunology
Research Office
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Information to be stored in this office:
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Copies of all current and future IRB submissions
Correspondence between IRB and investigators
including approval letters, audit reports, etc
Correspondence between sponsor and
investigators regarding protocol issues
RPF training certificates
Copies of current CV’s
Copies of current licenses
Human Immunology
Research Office
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To request assistance:
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Contact office to set up meeting to discuss project,
assistance requested, etc
Complete research outline (template will be
supplied by the office)
Contact information:
Location: E1540 BST
Phone: 412-624-6611
Email: [email protected]
Requirements Prior to IRB
Submission
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Possible UPMC fiscal approval
STI PRC (protocol review committee) approval
Any protocol submitted to the IRB requires prior
scientific review; PRC review includes scientific
review.
 submission is reviewed both by an investigator and a
research coordinator
 Facilitator of committee is Agnes Zachoszcz (all
submissions are emailed to her)
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