Protecting research participants and ensuring the collection of high quality meaningful data are the guiding principles for the oversight of clinical trials. The International Conference of Harmonization Good Clinical Practice guidelines provide uniform standards for the conduct of clinical trials and inform the regulatory framework for monitoring, although it is the sponsor's responsibility to ensure that the conduct of the trial meets specific standards.1 Data must be verifiable from source documents, and the conduct of clinical trial must match the approved protocol and be in compliance with applicable regulatory requirements. For multicenter trials, sponsors must ensure that data are comparable across trial sites and that all study personnel meet minimum training requirements that are clearly documented.2 Quality management approaches support the dual priorities of participant protection and data quality and are embraced by regulatory authorities.3,4
In the United States, the trial sponsor is the primary responsible party for the management of the clinical trial; however, Institutional Review Boards (IRBs) and Independent Safety Monitoring Committees also provide oversight of trial conduct. IRBs assure that appropriate steps are taken to protect the rights and welfare of participants in research, both in advance and by periodic review. They perform ethical review of the proposed research at particular sites and are required by US regulations for institutions receiving US government funds.5,6 In some resource-limited settings (RLS), review capacity may be limited by poor financial and human resources, insufficient training in ethics and inadequate standard operating procedures, highlighted in a recent review of the educational background, standard operating procedures and compliance with national guidelines of ethics committees.7 A mapping exercise of research ethics capacity in Africa underscored the need for ongoing research capacity growth and identified specific areas for development.8 The authors described a web-based interactive approach that allows for resource and process sharing and may ultimately improve both capacity and the quality of the reviews.
Study monitoring committees and data safety monitoring boards are composed of experts in the field and may also include statisticians, bioethicists, and often community representatives. They review accumulating data during the conduct of the trial and assess general progress and safety. Efficacy is frequently reviewed by treatment arm, and decisions may be made whether the trial has answered its primary question or is capable of answering the question. The committee typically receives unblinded data, and this information remains confidential.9 These committees make recommendations to the trial sponsors as follows: the trials may be stopped early for efficacy, futility, or safety concerns. The sponsors, the independent monitoring committees, and the IRBs have distinct but overlapping functions for the oversight of clinical trial conduct. The distinction between the roles may not always be clear, and a review of correspondence from several international clinical trials suggests that this may lead to tension between investigators, regulatory bodies, and sponsors.
Critical elements to monitor in all trials include adherence to informed consent procedures, inclusion and exclusion requirements, adequate and timely safety monitoring, adherence to protocol-mandated investigations and follow-up, and the review of regulatory documents. Specific methods of monitoring are not dictated by regulatory authorities and may include risk-based approaches, site visits triggered by specific events, and/or routine site visits. A risk assessment to identify the optimal means of monitoring, taking into account the likely sources of error, their consequences for the participants, and the available resources, is a proactive approach taken by the sponsors that may minimize risk to the participants. The use of electronic systems and modern statistical methods provide opportunities for creative monitoring approaches. Indeed, a flexible approach may be needed to ensure that the trial meets research goals.10 Targeted risk-based monitoring strategies rather than routine visits to all clinical sites with complete data verification streamline the approach to monitoring and may be cost-effective.11,12 Although the approach is attractive, and may be more likely to ensure overall study quality, onsite monitoring remains critical in many cases. Because inexperienced sites in RLS may meet criteria for “high risk”, there may be continued need for significant onsite monitoring efforts even with a risk-based approach. In a retrospective review of research site monitoring reports in Uganda, onsite monitors added value by identifying significant areas to be improved.13 A risk-based plan, therefore, might include both central monitoring and targeted local monitoring.14,15 The Division of AIDS has developed and is using risk-based criteria for monitoring intensity, but this rigor may not be widespread (Fig. 1).16 The evaluation of risk-adapted monitoring strategies for clinical trials is under investigation in 2 trials using a prospective cluster randomized approach.11,12,17
Pharmacovigilance is the specific evaluation in real time of drug safety and may identify safety signals in investigational agents. With the ongoing assessment of the safety of investigational agents for the participants, it is a critical element of trial conduct in both resource-rich and resource-limited settings. In addition to addressing the broad ethical requirement to protect research participant health, safety monitoring can also conserve resources by prompting the early discontinuation of unsafe investigational therapies and allow for timely changes to trial conduct that enhance participant safety. For example, eligibility criteria might be changed to exclude participants with evidence of hepatic or renal disease in response to an emerging safety signal. Safety monitoring may also increase the willingness of individuals to participate in trials due to greater confidence in the conduct of the study. However, currently there seems to be limited awareness by participants of the safety monitoring incorporated into trial designs.18,19
In the RLS, clinical trials intended to provide pivotal data have additional considerations with respect to safety monitoring. A crucial goal of these trials is to demonstrate the safety of therapies in a clinically meaningful way. However, if safety monitoring depends on strategies or tools that are not otherwise available where a trial is being conducted, then even if the trial is successful, the therapy under investigation may not ultimately be available to participants and trial participants may undergo the risks of the clinical trial without receiving the potential long-term benefits of having the investigational agent available for long-term use. There is an obligation to protect research participants to the extent possible, and providing less than optimal safety monitoring in RLS could be viewed as a failure of the sponsor to meet their obligations.5 Although there are no simple solutions, one approach is to consistently provide all safety monitoring considered medically necessary, regardless of the resources in that setting. If it is known in advance that clinical use of the therapy will require monitoring not available outside of the trial, and that particular monitoring capacity is unlikely to be developed, it has been argued that the research should be avoided.5 However, HIV-related research in RLS has been an iterative process, and enhanced laboratory and safety monitoring has led to increased availability of the recommended tests. For example, the requirement for liver function test availability when nevirapine is used has led to the support of the availability of this test at the district hospital level in President's Emergency Plan for AIDS Relief (PEPFAR)-supported countries.20,21 Provision of additional resources and training in RLS that would enable more advanced safety monitoring should be strongly encouraged. This would allow a broader range of trials to be performed ethically in RLS and could significantly impact the long-term health of individuals living in those communities and improve the standard of care.
Although monitoring represents an important mechanism for ensuring high quality data, it should be considered as only one element of an overall program of quality management. The site's role in driving quality improvements is a key tenet of an effective quality management program. It has been well described that third party identification and correction of errors does not lead to sustained process improvement.22 Development of a robust site quality management program which emphasizes self-identification of errors through continuous evaluation, root cause analysis, and implementation of corrective actions that may take the form of retraining process modification and implementation of new processes is essential to achieve sustained improvement. Other elements of a quality management plan include a well-designed protocol and case report forms, site staff training, and appropriate policies and procedures to oversee monitoring activities delegated to contractors.
In RLS, there may be unique practical challenges associated with monitoring and a proactive approach may avoid many issues (Table 1). Thinking about these issues during the protocol design and site activation phases may prevent significant risks to data quality that are difficult to manage once a study is enrolling, even with intense onsite monitoring. The practice of medicine is different than the conduct of a clinical trial, and clinicians may underestimate the time needed for clinical trial participation. Physicians may be used to making clinical diagnoses and treating empirically. Frequent testing and follow-up for laboratory abnormalities may be outside the usual practice patterns. Patients and clinicians may consider new symptoms and health events as part of the natural outcome of illness and not seek care or record symptoms in a medical record. Standards for record keeping may be very different: clinical records, if existent, may only document the chief complaint and prescribed medication. Shortages of ancillary personnel may delay filing of medical records; completion of data entry; and critical reports, including laboratory results, may be lost. Power supply fluctuations may create difficulties in uploading data over the internet and may have an impact on the compliance with guidelines for refrigeration of drugs and supplies. Space may be at a premium, and records may be stacked in storage areas that are not well protected from the environment and insects or rodents. This issue may also impact monitoring visits, and there may be little space for the study team and study monitors to review records when the clinic is open. Onsite monitoring is further impacted by the physical environment as follows: road conditions may prevent monitoring teams from accessing sites during rainy season, and monitoring teams may not have places to stay in remote areas overnight. In addition, sites in RLS participating in multiple networks and interacting with different trial sponsors may have to accommodate many different monitoring teams at varying intervals, adding to the workload of the already overburdened study staff. Data collection and reporting systems may also vary. All of these considerations compound the challenges of monitoring in RLS and emphasize the need for harmonization among trial sponsors and adequate resources to ensure compliance with International Conference of Harmonization guidelines.
The authors would like to thank Carole Andres and her team for the use of the protocol risk worksheet.
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