1 irb review and assessment of risks / benefits bernard lo, m.d. july 31, 2008
TRANSCRIPT
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IRB review andassessment of risks / benefits
Bernard Lo, M.D.
July 31, 2008
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Why do we have IRBs?
Why do we have federal research
regulations?
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Nazi “experiments”
1. Unacceptable risk
2. No consent
3. Use of vulnerable subjects
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Tuskegee study
1932 Study started
1936 Journal told that local MDs asked
not to treat subjects
1940 Subjects not treated in military
1947 USPHS Rapid Treatment Centers
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Tuskegee study
1968 Whistleblower Peter Buxtun
1969 CDC local chapters of AMA and
NMA reaffirm support,
1970 News coverage
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Tuskegee study
1974 DHEW issues regulations on
funded research
1974 Tuskegee Benefit Program
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Fundamental tension in research
Primary goal is generalizable
knowledge, benefit to society
Participants face risks but benefit to
others
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Ethical violations in Tuskegee
1. Inappropriate risk / benefit ratio
2. Lack of informed and voluntary
consent
3. Targeting of vulnerable population
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Regulations respond to Tuskegee
1. Beneficence Risks must be acceptable Risks must be minimized
2. Respect for persons Informed and voluntary consent
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Regulations respond to Tuskegee
3. Justice Equitable selection of subjects Protections for vulnerable subjects
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Federal requirements for research
Review by IRB Independent of investigators
Risks / benefits acceptable Risks must be minimized
• Must understand science
Include psychosocial risks• Confidentiality
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Federal requirements for research
Informed and voluntary consent Concerns about undue inducement if
payment Exceptions to consent
• Not capable of consent (children, adults who lack decision-making capacity)
• Impracticable to obtain consent
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Study 1: epidemiology of hepatitis C
Prospective cohort study of incidence
of hepatitis C and risk factors Blood draws Questionnaires
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Study 1: epidemiology of hepatitis C
Target population? Injection drug users Commercial sex workers
Vulnerable populations at higher risk
need special protection
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Study 1: epidemiology of hepatitis C
Medical risks minimal
Physical risks of questionnaires tiny
Psychosocial risks considerable Highly sensitive data
• Alcohol and substance abuse• Sexual behaviors, STDs, HIV• Illegal activities: sex for $, IDU• (Psychiatric illness)
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Study 1: epidemiology of hepatitis C
If confidentiality breached Legal risk: illegal activities Social harm: stigma, disruption of
relationships Economic harm: loss of employment
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Study 1: epidemiology of hepatitis C
How to minimize risks? Staff training Use coded or de-identified data Data security
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Study 1: epidemiology of hepatitis C
How to minimize risks? Data security
• Do not store identified data on laptops, removable devices
• Encryption Certificate of confidentiality
Inform participants of risk during
consent process
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Study 1: epidemiology of hepatitis C
Cannot guarantee absolute
confidentiality Reporting of communicable diseases Audits by funders
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Study 2: cholesterol-lowering drug
Phase II RCT to study whether new
drug to lower LDL prevents
progression of coronary disease Compare to standard statin Known to lower LDL more than statins
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Study 2: cholesterol-lowering drug
Primary endpoint is progression of
CAD on follow-up angiography
compared to baseline angiography
Secondary endpoints Combined cardiac death + MI Ischemia on exercise nuclear imaging
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Study 2: context
Drug already approved by FDA on
basis of LDL reduction
Is advantage in vascular progression a
surrogate endpoint? More power to detect surrogate endpoint
than clinical endpoint
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Question for audience
Would repeat angiography be indicated
in clinical care after starting patient on
lipid-lowering drug?
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Question for audience
Conceivable that detect L main
stenosis?
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Question for audience
Do you regard benefit / risk balance as
acceptable?
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Study 2: What are benefits of study?
Direct benefits intended by study
design Drug to lower LDL, monitoring of LDL ? Angiography
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Study 2: What are benefits of study?
Collateral benefits of being in study,
independent of research intervention Education about CAD risk Attention of staff Payment for participation
• May not be considered by IRB as benefit
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Study 2: What are risks of study?
Procedures that offer prospect direct
benefit Adverse effects of study drug
Procedures to answer research
question Risks of angiography
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Questions regarding Study 2
May invasive procedures not indicated
in clinical care be allowed in research?
How can risks and benefits of complex
study be combined into overall
assessment?
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For interventions that offer prospect of direct benefit
Greater level of risk acceptable than for
interventions solely for research
Balance of benefits / burdens should
be comparable to standard care
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For interventions that offer no prospect of direct benefit
May not justify by benefits of study
drug Study drug might reduce cardiac events
• May not justify by collateral benefits
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For interventions that offer no prospect of direct benefit
Risks must be reasonable compared to
potential knowledge gained
Risks must be minimized consistent
with valid research design
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In Study 2
Are risks minimized? Noninvasive means to assess progression of
vascular occlusion• CT angiography
• Doppler studies of carotid arteries
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In Study 2
What is potential knowledge gained? Is greater reduction in LDL clinically
meaningful?• What will this study add to what is already
known?
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Question for audience
Do you regard benefit / risk balance as
acceptable?
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Outcome of Study 2
Endpoint was progression of carotid
disease evaluated by Doppler
Study was negative study Was short-term benefit realistic?
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Looking ahead
When is IRB review not necessary? Not research Certain survey, interview research Certain research with existing data and
biological specimens
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Looking ahead
When may IRB review be expedited? Minimal risk in technical sense On list approved by DHHS
• Venipuncture
• Noninvasive• Not XRs
• Minor changes
• Continuing review
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Practical IRB tips on 8/14
Bring your questions!