Sham Studies and the Commercial IRBs that Approve Them, and Sham IRBs and the Government Department that Registers Them

We have occasionally posted about the activities of for-profit contract research organizations (CROs). These are commercial entities that conduct human research, including clinical trials for pharmaceutical, biotechnology and device companies. More clinical research is being done by such CROs rather than by academic investigators. CROs seem to operate under the radar of most physicians, academics, and policy makers, but sometimes stories surface that raise questions about them.

For example, we discussed the trials by SFBC International (now PharmaNet Development Group) in Miami that enrolled immigrants, often undocumented, under questionable circumstances and in Montreal that resulted in the transmission of active tuberculosis (see post here and links backward); and the trial by Parexel International in London that put most of its subjects in intensive care (see post here, with links backward). Last year, as we discussed here, two articles questioning the ethics of research done under the auspices of CRO appeared in two major medical journals.

In academia, human research is supposed to be overseen by institutional review boards (IRBs). Research done by CROs is also supposed to be overseen by IRBs, but the IRBs that do so are often also commercial. Despite concern that commercial IRBs may be tempted to lower their standards to get more business, commercial IRBs have flown even lower under the radar than have CROs. However, last week, a story appeared about how a "sting operation" tested one commercial IRB with amazing results. Here are excerpts from the article by Alicia Mundy in the Wall Street Journal,

The sting, detailed at a House Energy and Commerce Committee hearing Thursday, involved the creation of a fictitious company and a fake medical device, a surgical adhesive gel. The sham firm then applied to three for-profit oversight groups -- called institutional review boards, or IRBs -- for approval to begin a clinical trial using their adhesive on human subjects.

Two IRBs contacted by the GAO's sting operators -- Argus IRB of Arizona and Fox IRB of Illinois -- rejected the Adhesiabloc proposal because of unanswered safety questions.

'We realized it was a terrible risk for the patient … It is the worst thing I have ever seen,' an Argus IRB reviewer said, according to a slide shown at the hearing.

Coast IRB LLC of Colorado Springs, Colo., did approve a study for the fictitious adhesive gel, 'Adhesiabloc.'

The GAO also ran an experiment to see if the US Department of Health and Human Services (DHHS)would register a truly dubious commercial IRB

The committee, working with the Government Accountability Office, Congress's investigatory arm, named the CEO of the fake IRB Truper Dawg, after a staffer's three-legged dog, now deceased. Other fake names included 'April Phuls' and 'Timothy Wittless,' which lawmakers said should have signaled irregularities to HHS. The department registered the IRB.

On one hand, these anecdotes suggest, along with the stories discussed above, that CROs and the commercial IRBs that are supposed to oversee them deserve further scrutiny. Beyond that, one wonders if it is good for society for human research, including experiments involving drugs and devices, to be done by commercial firms dependent for their income on the companies that make these drugs and devices, overseen by other commercial firms also dependent on these same companies. The fundamental conflict is embodied by Coast IRB's self-description:

as an advocate and a catalyst for an ever-stronger pharmaceutical industry, ethically and economically.

which also

recognizes the vital importance of our role in protecting individuals in all clinical studies and in continuously raising the bar on professional standards.

How can the company be an "advocate" for the industry while simultaneously protecting the people exposed to the industry's still experimental drugs?

See also comments on the GoozNews blog.

Post Title → Sham Studies and the Commercial IRBs that Approve Them, and Sham IRBs and the Government Department that Registers Them

The Clinical Trials "Torture Economy"

Two recent commentaries in major medical journals on the same topic failed to get the recognition they deserved. Both were about exploitation of the poor in clinical research, usually in Phase I drug trials conducted by contract research organizations (CROs), supervised by for-profit institutional review boards (IRBs), and both paid by pharmaceutical, biotechnology or device companies.

The first article was by Carl Elliott and Roberto Abadie. [ Elliott C, Abadie R. Exploiting a research underclass in phase I clinical trials. N Engl J Med 2008; 358: 2316-7. Link here.] Per Elliott and Abadie, the context is:

Over the past decade, clinical trials have moved from universities to private testing sites, the pressure to recruit subjects quickly has intensified, and ethical oversight has been outsourced to for-profit institutional review boards (IRBs). Payment to subjects has escalated, creating 'shadow economies' in cities throughout North America and elsewhere.

The authors then cited several misadventures that we have discussed on Health Care Renewal: the trials by SFBC International (now PharmaNet Development Group) in Miami that enrolled immigrants, often undocumented, under questionable circumstances and in Montreal that resulted in the transmission of active tuberculosis (see post here and links backward); and the trial by Parexel International in London that put most of the subjects in intensive care (see post here, with links backward).

Elliott and Abadie concluded "there are good reasons to believe that poor subjects are being exploited," and cited several justifications for this belief:

• "Poor people are less likely than wealthier ones to get access to the drugs in question." This "appears to contravene article 19 of the Declaration of Helsinki, which states that medical research is ethically justified only if there is a reasonable chance that the population in which it is conducted will benefit from the results."
• "The U.S. oversight system is not well equipped to monitor a highly competitive, market-based, multinational research industry." The Office for Human Research Protection "has no jurisdiction over privately sponsored studies," the US Food and Drug Administration (FDA) has insufficient funds to monitor all but a tiny minority of trials. The institutional review boards (IRBs) that are supposed to supervise trials are ill-equipped to protect against the sort of abuses that are likely. Furthermore, for-profit IRBs that are dependent on research sponsors for repeat business may be loathe to upset the apple-cart.
• "Most sponsors apparently do not provide free care or treatment when subjects are injured."

Elliott and Abadie observed that most subjects in such trials see their participation as a job, rather than as a voluntary activity to promote science and human welfare. As the authors point out, if so, it is a poorly paid, risky job with few benefits and protections. Their conclusion is troubling,

The result is what one Philadelphia trial subject describes as 'a mild torture economy.' 'You are not being paid to do something,' he explains. 'You are being paid to endure.'

The only addition I can make is not only does the treatment of some patients in such trials appear inhumane, it amounts to bad science. Results from "professional trial subjects," who are likely to conceal characteristics which might have excluded them from this line of work, who may undergo one trial while still recovering from the effects of a previous, undisclosed trial, and who may be prone not to follow study protocols likely will not generalize to the patients who might actually be candidates for the drugs and devices assessed.

An editorial in the American Journal of Medicine was based on an article by Carl Elliott on the same topic published in the New Yorker. [Alpert JS. Dealing with ethical conflicts in clinical research. Am J Med 2008; 121: 457. Link here.]

His main conclusions were:

The ethical failure of such activities is obvious. The Nuremburg and Helsinki codes, developed following the human experimental atrocities of World War II, strongly advocate for voluntary participation on the part of research subjects. The substantial sums of money paid to the human 'guinea pigs' described by Elliott clearly obfuscate any volunteerism on the part of the individuals involved in these clinical experiments.

Lives saved and disease suffering lessened at the expense of individuals who are lured and perhaps even coerced into clinical trial participation cannot be allowed to continue in an open and equitable democracy. Clearly, the article by Elliott should be widely disseminated among academic and community physicians and governmental authorities. The topic should be openly discussed leading to corrective actions. Steps must be taken in the near future to protect the lives and the civil rights of individuals participating in clinical research studies.

Despite this call, I found no news coverage, and so far, no public discussion of any kind of the issues raised by these articles.

I hope that the charges that many current trials violate international ethical standards might get some peoples' attention, and maybe even inspire some action. I am not optimistic that anything will be done too hastily. After all, a lot of people are benefiting financially by the current scandalous status quo. They will not give up their ill-gotten gains gracefully. But this "mild torture economy" signals the approaching moral bankruptcy of our current health care system.

Post Title → The Clinical Trials "Torture Economy"

An Idiotic Review Board? AKA The Office for Human Research Protections

Another view on this post "Why was this QI Project Shut Down":

It is possible to adhere to institutional "process" so blindly and so obstinately, ignoring common sense (which may not be all that common) as to impair medical progress.

It has been also said that "process" is no substitute for smart people, but tries to be, based upon beliefs in management theories (a.k.a. "management mysticism") and simplistic, mechanistic views about how the world really works. Unfortunately, any theory, rule, or process taken too far or adhered to too rigidly can have major downsides.

The case below is such an example of this, where process trumps common sense, cleverness trumps wisdom:

A Lifesaving Checklist
By ATUL GAWANDE
New York Times, Dec. 30, 2007

In Bethesda, Md., in a squat building off a suburban parkway, sits a small federal agency called the Office for Human Research Protections. Its aim is to protect people. But lately you have to wonder. Consider this recent case.

A year ago, researchers at Johns Hopkins University published the results of a program that instituted in nearly every intensive care unit in Michigan a simple five-step checklist designed to prevent certain hospital infections. It reminds doctors to make sure, for example, that before putting large intravenous lines into patients, they actually wash their hands and don a sterile gown and gloves.

The results were stunning. Within three months, the rate of bloodstream infections from these I.V. lines fell by two-thirds. The average I.C.U. cut its infection rate from 4 percent to zero. Over 18 months, the program saved more than 1,500 lives and nearly $200 million.

Yet this past month, the Office for Human Research Protections shut the program down. The agency issued notice to the researchers and the Michigan Health and Hospital Association that, by introducing a checklist and tracking the results without written, informed consent from each patient and health-care provider, they had violated scientific ethics regulations. Johns Hopkins had to halt not only the program in Michigan but also its plans to extend it to hospitals in New Jersey and Rhode Island.

The government’s decision was bizarre and dangerous. But there was a certain blinkered logic to it, which went like this: A checklist is an alteration in medical care no less than an experimental drug is. Studying an experimental drug in people without federal monitoring and explicit written permission from each patient is unethical and illegal. Therefore it is no less unethical and illegal to do the same with a checklist. Indeed, a checklist may require even more stringent oversight, the administration ruled, because the data gathered in testing it could put not only the patients but also the doctors at risk — by exposing how poorly some of them follow basic infection-prevention procedures.

For the love of god ... perhaps only a bureaucrat is capable of such idiotic thinking? Most if not all of the items on the checklist could be read in any introductory text on medicine or The Washington Manual. They were reminders of the obvious, not experimental protocols.

The overly litigious and predatory nature of U.S. healthcare also affected the thinking of the Office for Human Research Protections, I'm sure, and this idiocy is perhaps another example of the pernicious effects of the litigiousness. Predatory lawyers and bumbling bureacrats are not among my list of primary actors for creation of sound medical policy.

... Excellent clinical care is no longer possible without doctors and nurses routinely using checklists and other organizational strategies and studying their results. There need to be as few barriers to such efforts as possible. Instead, the [checklist] endeavor itself is treated as the danger.

If the government’s ruling were applied more widely, whole swaths of critical work to ensure safe and effective care would either halt or shrink: efforts by the Centers for Disease Control and Prevention to examine responses to outbreaks of infectious disease; the military’s program to track the care of wounded soldiers; the Five Million Lives campaign, by the nonprofit Institute for Healthcare Improvement, to reduce avoidable complications in 3,700 hospitals nationwide.

... Scientific research regulations had previously exempted efforts to improve medical quality and public health — because they hadn’t been scientific. Now that the work is becoming more systematic (and effective), the authorities have stepped in. And they’re in danger of putting ethics bureaucracy in the way of actual ethical medical care. The agency should allow this research to continue unencumbered. If it won’t, then Congress will have to.

Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a New Yorker staff writer, is the author of “Better."

The "process fanatic" will be the death of good medicine, including those who believe that all of medicine can be deterministically modeled and cybernetic miracles worked with EHR's.

Speaking of religion, and considering the above report came out just after Christmas, the following humorous but meaningful piece comes to mind. Ironically, both the NYT story and the piece below were sent to me by different parties independently at around the same time:

IRB Global Observational Study of Behavior in Children review

Dr. K Kringle
Adjunct Professor of Child Psychology
Far Northern University

Dear Dr. Kringle (Ph.D, M.D., D.O.? Please verify your credentials):

At the regularly scheduled December 24 meeting, the IRB reviewed your protocol, "A Global Observational Study of Behavior in Children" While we believe it has many good features, it could not be approved as submitted. If you choose to revise your study, please address the following IRB concerns:

1. You propose to study "children of all ages." Please provide an exact lower and upper age limit, as well as the precise number of subjects. Provide a statistically valid power calculation to justify this large of a study.

2. Your only inclusion criterion is "belief in Santa Claus." Please provide a copy of the screening questionnaire that determines such a belief. Provide a Waiver of Authorization under MPAA in order to record these beliefs prior to enrollment in your study. The Board recommends that you obtain a Certificate of Confidentiality as beliefs are sensitive and personal information.

3. You propose to "know when they are sleeping and know when they are awake." How will this be done? Will children undergo video monitoring in their beds? Will they have sleep EEGs? You list 100 elves as research assistants. Are any of them sleep physiologists? Please provide credentials of elves.

4. Your primary outcome measure is to "know when they've been bad or good." What standard is being used to determine "goodness"? Do children have to be good all year or just most of the time? Please specify required duration and provide the instrumentation, with appropriate consent forms, that will be used for operationally defining "goodness."

5. You propose to conduct your research by entering the subjects' homes through the chimney. Have you considered the liability potential, i.e., damage to the roof, carpeting, etc., that this will cause? Moreover, children are likely to be startled by your appearance late at night. Please revise your protocol to conduct your home visits between 9 am and 5 pm Monday through Friday with at least one parent being present and all risks and benefits carefully described.

6. You state that compensation for participation will be "sugarplums, candy, and toys" for the good little girls and boys. This may not be appropriate for the children with obesity, dental cavities, and hyperactivity. Also, your proposal to leave a lump of coal in the stockings of the bad children will be unfairly stigmatizing to them individually and as a group. In general, the Board suggests a small token of appreciation for all participants. Perhaps a $5 Toys-R-Us gift card would be more appropriate in order to avoid potential coercion.

7. The database of good and bad children will be kept "on a scroll at the North Pole." Please describe the location of the scroll and the security provisions you have in place to protect the data Is the scroll kept in a locked cabinet in a locked room? Who has access to the scroll? Are there backup copies of the scroll and how often are they compared to the original?

8. You mention the participation of "eight tiny reindeer" in your protocol. Please provide the Board with documentation of Institutional Animal Care and Use Committee approval.

9. Please provide the Human Subjects Protection training dates for Mrs. Claus and the elves.

10. As this study involves prospective data collection and is more than minimal risk without prospect of direct benefit to the subjects, informed consent signed by both parents will be required. Please have the consent form translated into every language spoken by children and ensure that assent forms are signed by all.

Please submit 25 copies of your revised protocol to the IRB. The IRB will be on Holiday Season schedule for the next two weeks. If approved, you will be able to conduct your study sometime in the spring, if all items are appropriately addressed.

Sincerely,
E. Scrooge, MD

Chair, Institutional Review Board

Copyright 2006, David R. Karp

-- SS

Post Title → An Idiotic Review Board? AKA The Office for Human Research Protections