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Original Research: Critical Care Medicine |

Surrogate Receptivity to Participation in Critical Illness Genetic ResearchSurrogate Receptivity to Genetic Research: Aligning Research Oversight and Stakeholder Concerns FREE TO VIEW

Bradley D. Freeman, MD; Kevin Butler, MS; Dragana Bolcic-Jankovic, MS; Brian R. Clarridge, PhD; Carie R. Kennedy, RN; Jessica LeBlanc, BA; Sara Chandros Hull, PhD
Author and Funding Information

From the Department of Surgery (Dr Freeman, Mr Butler, and Ms Kennedy), Washington University School of Medicine, St. Louis, MO; the Center for Survey Research (Mss Bolcic-Jankovic and LeBlanc and Dr Clarridge), Boston, MA; and the Center for Clinical Bioethics (Dr Chandros Hull), National Institutes of Health, Bethesda, MD.

CORRESPONDENCE TO: Bradley D. Freeman, MD, Washington University School of Medicine, Department of Surgery, Campus Box 8109, 660 S Euclid Ave, St. Louis, MO 63110; e-mail: freemanb@wustl.edu


FUNDING/SUPPORT: This study was supported by National Institutes of Health [Grant GM080591] and by the intramural research program of the National Human Genome Research Institute.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(4):979-988. doi:10.1378/chest.14-0797
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Published online

BACKGROUND:  Collection of genetic biospecimens as part of critical illness investigations is increasingly commonplace. Oversight bodies vary in restrictions imposed on genetic research, introducing inconsistencies in study design, potential for sampling bias, and the possibility of being overly prohibitive of this type of research altogether. We undertook this study to better understand whether restrictions on genetic data collection beyond those governing research on cognitively intact subjects reflect the concerns of surrogates for critically ill patients.

METHODS:  We analyzed survey data collected from 1,176 patients in nonurgent settings and 437 surrogates representing critically ill adults. Attitudes pertaining to genetic data (familiarity, perceptions, interest in participation, concerns) and demographic information were examined using univariate and multivariate techniques.

RESULTS:  We explored differences among respondents who were receptive (1,333) and nonreceptive (280) to genetic sample collection. Whereas factors positively associated with receptivity to research participation were “complete trust” in health-care providers (OR, 2.091; 95% CI, 1.544-2.833), upper income strata (OR, 2.319; 95% CI, 1.308-4.114), viewing genetic research “very positively” (OR, 3.524; 95% CI, 2.122-5.852), and expressing “no worry at all” regarding disclosure of results (OR, 2.505; 95% CI, 1.436-4.369), black race was negatively associated with research participation (OR, 0.410; 95% CI, 0.288-0.585). We could detect no difference in receptivity to genetic sample collection comparing ambulatory patients and surrogates (OR, 0.738; 95% CI, 0.511-1.066).

CONCLUSIONS:  Expressing trust in health-care providers and viewing genetic research favorably were associated with increased willingness for study enrollment, while concern regarding breach of confidentiality and black race had the opposite effect. Study setting had no bearing on willingness to participate.

Genetic variation influences disease predisposition and severity.1,2 Use of genetic information to aid diagnosis, stratify risk, and guide therapy has potential to impact most facets of medical practice.24 Substantial investment has produced greater understanding of genetic structure and refinement in techniques to facilitate acquisition and analysis of genetic data in a cost-effective fashion.57 Genetic biospecimens are commonly collected in observational studies and as adjuncts to therapeutic trials.8 Comparable investigations involving acutely ill patients are increasingly commonplace and essential to advancing the field of critical care medicine.4,9,10

Critically ill patients are frequently incapacitated, requiring that informed consent permitting research participation be obtained from surrogate decision-makers (eg, family members, guardians, or domestic partners).1115 Investigations involving incapacitated subjects are often perceived as entailing greater participant risk relative to studies enrolling cognitively intact individuals.1118 Several core protections have been proposed to govern research in this context.17,18 Among these is an institutional assessment of the risks and benefits of any proposed study.1719 Gong et al19 surveyed institutional review board (IRB) members to understand how this particular protection might be applied. When presented with a hypothetical study involving incapacitated patients in which genetic specimens would be collected, respondents were conflicted as to the risk such a study would pose, with 40% reporting that they would not permit such a study in the absence of direct patient benefit.19 Variability in application of research protections has likewise been observed in clinical investigations. In a multicenter, genetic epidemiology, acute stroke trial, Chen et al20 reported that investigators preferentially enrolled less severely affected, cognitively intact participants, because IRBs at 40% of participating institutions would not permit use of decisional surrogates to provide consent in such a study.

IRBs are charged with insuring the protection of research participants in a manner consistent with federal statute and prevailing standards.11,18,19 Within this framework, variable application of research subject protections among institutions is problematic insofar as it introduces inconsistencies in recruitment practices and potential for sampling bias.21,22 Further, to the extent that protections are applied that do not address concerns of research subjects, they are ineffective. There is growing enthusiasm for the investigative community to engage potential research participants in issues of trial design and human subjects’ protection.2325 We undertook this study to better understand whether restrictions on genetic data collection beyond those governing research on cognitively intact subjects reflect the concerns of surrogates for critically ill patients. Insight into stakeholder preferences holds the potential for achieving greater alignment between research oversight practices and the concerns that those who are directly affected express.24

Overview

We sought to determine whether protections beyond those governing research involving cognitively intact participants reflect preferences of those who might be approached with requests to a enroll a patient in a critical illness study. To understand these preferences, we examined receptivity to participation in a low-risk study involving genetic sample collection, comparing two populations: ambulatory patients rendering decisions for themselves and surrogates providing substituted judgment for critically ill adults. This was accomplished by aggregating common elements from surveys that had been administered to these two subpopulations.26,27 The findings from the ambulatory study have been published previously.26

Data Acquisition

Briefly, the questionnaire to understand attitudes about participation in genetic research was developed with extensive expert review.26,27 For the ambulatory study, respondents were enrolled from a convenience sample of adult outpatients at one of five academic health centers (2002 to 2003). For the critical care portion of this study, participants were recruited from surgical and medical ICUs of three tertiary care institutions (March 2010 to December 2012). We sought to interview surrogates actively engaged in the process of providing substituted judgment for critically ill adults. At study initiation, ICU admissions were screened to identify patients who were ≥ 18 years old, who were mechanically ventilated for ≥ 48 h, and who were expected to require ventilatory support for ≥ 24 additional hours. Excluded patients were those who were prisoners, pregnant, had sustained severe head injury, or who possessed preexisting cognitive dysfunction. Surrogates (ie, family members, guardians, domestic partners, legally appointed individuals) for patients meeting inclusion criteria were approached by research staff and invited to participate. All surveys were conducted by dedicated field interviewers. Participant responses were recorded electronically and submitted in a deidentified fashion to a central repository for coding and analysis (e-Appendix 1).

Analysis

Three authors (B. D. F., K. B., S. C. H.) reviewed the surveys administered in these individual studies to identify common elements that could be pooled for analysis.26,27 In addition to demographic variables, these elements included familiarity with genetic research, perception of genetic research, willingness to permit collection of a genetic sample, and concern about unauthorized disclosure of genetic study data (e-Table 1). The approach to analysis was comparable to that previously described.26 Our primary goal was to examine receptivity to genetics research participation, comparing ambulatory patients making decisions for themselves and surrogates providing substituted judgment for critically ill adults. We defined receptivity as follows. Interviewees were asked about the likelihood that they would provide a genetic sample (ambulatory setting) or permit the collection of a genetic sample for an incapacitated patient (critical care setting). The responses “very likely” and “somewhat likely” were categorized as “receptive”; the responses “not very likely” and “not at all likely” were categorized as “nonreceptive.” The Wald Χ2 statistic was used to compare ambulatory and critical care populations and to examine the relationship between dependent (ie, receptivity vs nonreceptivity) and independent variables. Multivariate logistic regression was used to examine the relationship between population (ie, ambulatory, critical care) and variables associated with receptivity to genetic research (SigmaPlot 12.5; Systat Software Inc). Files with missing data elements were excluded from multivariate analysis.

Human Subject Protections

This study was approved by the IRBs of Washington University School of Medicine (201303067) and the National Institutes of Health (02-HG-N237).

Participant Characteristics

We analyzed data from 1,613 respondents (Table 1, e-Appendix 1). These individuals were predominately middle aged, female (71.9%), and white (74.7%). While the majority (73.7%) categorized themselves collectively as being in “good,” “very good,” or “excellent” health, a substantial number (56.4%) described carrying the diagnosis of a chronic illness. Seventy percent reported completing at least some college course work, and a similar proportion endorsed “complete trust” in their health-care provider. A minority (42.1%) reported being “very religious.” While the 1,176 ambulatory patients and 437 surrogates were comparable with respect to sex, age, race, ethnicity, and degree of trust placed in health-care providers (p was not significant for all), these two groups had notable distinctions. Compared with surrogates, a higher proportion of ambulatory participants reported that they were in fair or poor health and carried the diagnosis of chronic illness (P < .001 for both) and were more likely to report that they had previously participated in research (P < .001). Finally, while a greater proportion of surrogates described themselves as “very religious,” smaller proportions of these individuals were in the extreme strata of education and income (P < .05 for all).

Table Graphic Jump Location
TABLE 1 ]  Demographic Variables Comparing Ambulatory Patients and Surrogates for Critically Ill Individuals

Data are presented as No. (%) unless otherwise indicated. IQR = interquartile range.

a 

Numbers in parentheses refer to participants analyzed for survey element.

b 

Includes Asian, American Indian, and other races.

Attitudes About Genetic Research

Interviewees described a general familiarity with genetic research, tended to view this type of research favorably, and reported being “very willing” (52.2%) or “somewhat willing” (30.4%) to permit genetic sample collection (Table 2). Despite the majority of respondents (70.5%) endorsing “complete trust” in their health-care provider, concerns about inadvertent disclosure of genetic results were common, with nearly 60% of individuals stating that this was at least a “moderate worry.” Ambulatory patients and surrogates differed in several key respects. While surrogates were more likely to report that they had “heard a lot about” or “heard a little about” genetic research, they were less likely to view this research positively, to describe willingness to permit genetic data collection, or to express concerns regarding unauthorized disclosure of results (P < .001 for all).

Table Graphic Jump Location
TABLE 2 ]  Survey Responses Related to Attitudes Concerning Genetic Research Comparing Ambulatory Patients and Surrogates for Critically Ill Individuals

Data are presented as No. (%) unless otherwise indicated.

a 

Numbers in parentheses refer to participants analyzed for survey element.

Relationship Between Participant Characteristics, Attitudes About Genetic Research, and Receptivity to Genetic Research Participation

We explored differences among participants who were receptive and nonreceptive to permitting genetic sample collection. Compared with nonreceptive individuals (n = 280; 185 ambulatory, 95 surrogates), receptive participants (n = 1,333; 991 ambulatory, 342 surrogates) were older, more commonly white, and more likely to report higher annual income. Similarly, these individuals were more likely to carry the diagnosis of chronic illness, to have previously participated in research, and to place trust in health-care providers (P < .05 for all) (Table 3). Ambulatory patients appeared more receptive to research participation than surrogates (84.3% vs 78.3%, P = .006). In contrast, receptive and nonreceptive participants were similar with respect to sex, ethnicity, religiosity, and education level (P was not significant for all). Receptive and nonreceptive participants differed in their attitudes about genetic research, with receptive individuals more likely to report familiarity with this field and to view it positively, and to be less concerned regarding disclosure of results (P < .001 for all) (Table 4).

Table Graphic Jump Location
TABLE 3 ]  Demographic Variables Comparing Participants Receptive and Not Receptive to Genetic Sample Collection

Data are presented as No. (%) unless otherwise indicated. See Table 1 legend for expansion of abbreviation.

a 

Numbers in parentheses refer to participants analyzed for survey element.

b 

Includes Asian, American Indian, and other races.

Table Graphic Jump Location
TABLE 4 ]  Survey Responses Related to Willingness to Provide a Genetic Sample for Research Comparing Interviewees Receptive and Not Receptive to Genetic Sample Collection

Data are presented as No. (%) unless otherwise indicated.

a 

Numbers in parentheses refer to participants analyzed for survey element.

In multivariate analysis of the pooled sample, reporting “complete” trust in health-care providers, upper income strata, viewing genetic research “very” positively, and expressing “no worry at all” regarding disclosure of results were positively associated with receptivity to research participation, whereas black race was associated with decreased likelihood of participation (P < .05 for all). We did not detect an effect of subpopulation (ie, ambulatory patients compared with surrogates for critically ill individuals) on receptivity to enrollment in a genetic study (P was not significant) (Table 5). When analyzed independently, the only variable that differed significantly when comparing ambulatory patients and surrogates was expressing complete trust in the health-care provider (OR, 2.226 [95% CI, 2.290-4.861] vs 1.160 [0.650-2.069]; P < .05 for ambulatory patients vs surrogates, respectively) (e-Table 2).

Table Graphic Jump Location
TABLE 5 ]  ORs and 95% CIs for Relationship Between Survey Elements and Receptivity to Providing Genetic Sample for Researcha
a 

Hosmer-Lemeshow statistic: 7.732 (P = .460).

We sought to identify factors affecting receptivity to participation in genetic research and found that expressing trust in health-care providers and viewing this type of research favorably were associated with increased willingness for enrollment. In contrast, concern regarding breach of confidentiality and black race had the opposite effect. Reassuring potential research subjects as to the confidentiality of research data, as well as describing the safeguards in place to maintain this confidentiality, would appear to be a modifiable variable that might favorably impact recruitment.

This study was based on the premise that human subjects’ protections should mirror the concerns expressed by those directly affected (ie, the research subjects themselves).2325 We reasoned that application of research restrictions based on setting would be reflected in willingness of individuals approached in these contexts to participate. Scenarios presented to ambulatory patients and surrogates described low-risk studies. Among possible outcomes from this comparison, we speculated that surrogates, when confronted with the exigencies of the ICU environment, might have heightened concerns about research participation and be less willing to permit genetic sample collection relative to patients in the ambulatory setting.2830 Alternatively, relative to the risks associated with conditions prompting ICU admission and with procedures necessary to provide care, we reasoned that surrogates might perceive the risks associated with research as trivial and be more permissive with respect to enrollment. Either outcome would suggest potential vulnerability on the part of surrogates and would argue for greater stringency in research subjects’ protections for genetic research conducted in the critical care environment. However, in multivariate analysis, we found that ambulatory patients and surrogates were indistinguishable with respect to their willingness to participate in genetic research. One interpretation of this finding is that human subjects’ protections should likewise be comparable in these two settings; imposition of additional protections would not appear to match concerns held by surrogates approached for research participation.

To our knowledge, this is the first study to directly compare attitudes about clinical research among individuals in ambulatory and critical care settings. Important differences existed between these subpopulations. Reflecting that ambulatory participants were recruited from outpatient clinics, these individuals more commonly described poor chronic health relative to surrogates. Similarly, because one ambulatory enrollment site recruited patients who had previously participated in an epidemiologic investigation, these individuals were more likely to report previous research experience. Finally, while surrogates reported greater familiarity with genetic research, they were less likely to view this technology positively.

A number of investigators have examined the relationship between race and clinical trial participation.3134 While our methodology did not allow us to explore the reasons for less receptivity to clinical research among blacks, this finding did not appear explained by education, income, religiosity, or trust. Coupled with other factors common in underrepresented populations, racially associated reluctance to enroll in critical care research presents a significant hurdle to achieving broad demographic inclusion and for rectifying racial disparities in critical care.33,35,36 Further, these findings suggest that motivations for participation in clinical investigation may largely be formed prior to the ICU experience. Understanding the concerns of underrepresented groups and determining how best to surmount these concerns might be further pursued using qualitative methodology.

Our study had several limitations. Individuals might execute the surrogate role in one of several ways, such as providing substituted judgment (reflecting what the incapacitated patient would wish for themselves) or engaging in decision making based on what the surrogate perceives is in the patient’s best interest. We did not provide guidance as to what framework participants should adopt in responding to our survey and cannot exclude the possibility that providing this background might have altered their responses. In addition, acquisition of data from the two surveys analyzed differed in time. Attitudes might have been affected by portrayal of genetic technology in the mass media, as well as reporting of legislative initiatives such as the Genetic Information Nondiscrimination Act.37 Further, while we intended the concept of trust as used in our survey instruments to measure confidence in health-care providers, this term is open to variable interpretation, which may have affected our findings.38 Similarly, due to sampling bias and exclusion of incomplete surveys, the opinions we report may not be representative of the broader population, further limiting the generalizability of our results.39,40 Finally, we solicited attitudes about participation in a hypothetical low-risk study. We may have detected a divergence in interest in participation among the groups sampled if we had included scenarios of variable risk.41 Similarly, opinions we recorded may not reflect an individual’s consideration if approached about an actual clinical study. Nonetheless, our findings are consistent with those reported by Smart et al,9 who found that the majority of surrogates granting permission for participation in clinical trials coordinated through the Acute Respiratory Distress Syndrome Network likewise permitted genetic specimen collection, and that patients largely affirmed participation when given the opportunity for reconsent.

Receptivity to participation in genetic research was similar comparing ambulatory patients and surrogates for critically ill adults. These findings suggest that restrictions imposed by IRBs on genetic research involving incapacitated individuals, beyond those governing research for cognitively intact participants, may impede valuable investigations without conferring any meaningful and offsetting human subjects’ protections. Achieving greater alignment between stakeholder preferences and research subjects’ protections may be one strategy for minimizing interinstitutional variation in IRB behavior. While this study focused on a specific field of inquiry, we feel that this approach is applicable to other domains where ambiguity exists as to the manner in which research subject protections might be optimally applied.

Author contributions: B. D. F. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. B. D. F. and S. C. H. served as co-principal investigators for this study and contributed to writing the manuscript; B. D. F., K. B., D. B.-J., B. R. C., J. L., and S. C. H. contributed to manuscript development; B. D. F., K. B., D. B.-J., B. R. C., J. L., and S. C. H. contributed to project conception; K. B., D. B.-J., B. R. C., and C. R. K. contributed to data acquisition; and B. D. F., K. B., D. B.-J., B. R. C., C. R. K., and S. C. H. contributed to data analysis.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Mss Bolcic-Jankovic and LeBlanc and Dr Clarridge are employees of the Center for Survey Research, University of Massachusetts-Boston. This affiliation does not create a conflict with the material presented. Further, there are no commercial affiliations or arrangements concerning any of the authors which would in any way create such a conflict. Drs Freeman and Chandros Hull, Mr Butler, and Ms Kennedy have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The funding agencies played no role in this study or manuscript beyond providing financial support. The views expressed are those of the authors and do not necessarily reflect those of Washington University School of Medicine, the National Human Genome Research Institute, the National Institutes of Health, or the Department of Health and Human Services.

Other contributors: The authors are indebted to the nurses, physicians, patients, family members, and personnel of the medical and surgical ICUs of Barnes Jewish, Parkland, and St. Louis University Hospitals, whose generous cooperation and support made this study possible. The assistance of the support staff at Center for Survey Research (University of Massachusetts-Boston) is likewise greatly appreciated. The investigators also wish to acknowledge the contribution of Jonathan Fix to the development of this manuscript.

Additional information: The e-Appendix and e-Tables can be found in the Supplemental Materials section of the online article.

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Figures

Tables

Table Graphic Jump Location
TABLE 1 ]  Demographic Variables Comparing Ambulatory Patients and Surrogates for Critically Ill Individuals

Data are presented as No. (%) unless otherwise indicated. IQR = interquartile range.

a 

Numbers in parentheses refer to participants analyzed for survey element.

b 

Includes Asian, American Indian, and other races.

Table Graphic Jump Location
TABLE 2 ]  Survey Responses Related to Attitudes Concerning Genetic Research Comparing Ambulatory Patients and Surrogates for Critically Ill Individuals

Data are presented as No. (%) unless otherwise indicated.

a 

Numbers in parentheses refer to participants analyzed for survey element.

Table Graphic Jump Location
TABLE 3 ]  Demographic Variables Comparing Participants Receptive and Not Receptive to Genetic Sample Collection

Data are presented as No. (%) unless otherwise indicated. See Table 1 legend for expansion of abbreviation.

a 

Numbers in parentheses refer to participants analyzed for survey element.

b 

Includes Asian, American Indian, and other races.

Table Graphic Jump Location
TABLE 4 ]  Survey Responses Related to Willingness to Provide a Genetic Sample for Research Comparing Interviewees Receptive and Not Receptive to Genetic Sample Collection

Data are presented as No. (%) unless otherwise indicated.

a 

Numbers in parentheses refer to participants analyzed for survey element.

Table Graphic Jump Location
TABLE 5 ]  ORs and 95% CIs for Relationship Between Survey Elements and Receptivity to Providing Genetic Sample for Researcha
a 

Hosmer-Lemeshow statistic: 7.732 (P = .460).

References

Collins FS, Green ED, Guttmacher AE, Guyer MS; US National Human Genome Research Institute. A vision for the future of genomics research. Nature. 2003;422(6934):835-847. [CrossRef] [PubMed]
 
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