Understanding and Addressing Barriers to Recruitment
Published Online: March 20, 2014
Jennifer L. Redmond, DrPH
Patients fear being a guinea pig or receiving a placebo, healthcare providers do not have time to keep up with all the clinical trial information or talk with patients in depth, conducting clinical trials are very expensive for healthcare systems and funding continues to decline for research. With all these barriers, it’s not surprising that clinical trial recruitment remains around 1.7% for adults.1
Many professionals throughout the country, including oncology nurses, surgeons, medical oncologists and researchers, have identified best practices and resources to help overcome many of these barriers, improve informed decision-making and increase clinical trial recruitment. Six professionals, actively involved in clinical trial education, navigation, review, recruitment and research, provided their perspectives on barriers and best practices:
• Oncology nurses
° Sue Childress, RN, MN, OCN, director of nursing at the Huntsman Cancer Institute, Salt Lake City, UT
° Cindy Davidson, APRN, clinical operations manager at the Huntsman Cancer Hospital in Salt Lake City, UT
° Joyce Schaffer, RN, MSN, AOCNS, clinical trials patient navigator with Scottsdale Healthcare in Scottsdale, AZ
° Timothy Mullett, MD, cardiothoracic surgeon at the University of Kentucky, Lexington, Kentucky and director of the Kentucky Clinical Trials Network
° Leigh Neumayer, MD, a general surgeon specializing in breast cancer at the Huntsman Cancer Institute, Salt Lake City, UT
° Margaret Byrne, PhD, associate professor at the University of Miami, Florida, focused on new tools related to informed decision making and clinical trials.
Barriers and best practices can be found at many places in the clinical trial system. These relate to the patient and family who may be fearful or confused by the trial, the healthcare professional who has no time to spend on clinical trials, and the healthcare system that struggles with handling the cost and inefficiencies of conducting clinical trials.
Patient and Family Barriers
Fear was touted as the greatest barrier for patients and families, particularly the fear of being a guinea pig or receiving a placebo rather than treatment. Patients may not know that clinical trials were an option, and if they did know, they may see participation as a last resort. Some also believe that a drug already approved by the US Food and Drug Administration (FDA) would be better than a drug that is not yet approved.
Clinical trials can be complicated and confusing. Some patients would rather just say “no” to participation because it is easier. When conducting in-depth interviews with 45 minority patients, Byrne asked about whether they participated in a clinical trial. After providing information on their treatment experiences, many patients asked her if they had participated in a clinical trial.
Cost is another patient barrier. These costs include: travel, time off work, and cost of procedures, particularly if the patient is uninsured. Insured patients may be concerned that there will be unexpected costs that are not covered by their insurance. Some patients have limited insurance plans with minimal out-of-network benefits and many patients do not know the rights they have within their plans. Depending upon the way a patient asks the question, they may receive a different response. As Schaffer said, “If a person calls an insurance company and asks if they will provide coverage for a clinical trial, they will say “no”, but if that person asks if they will cover the standard of care in a clinical trial, then they will say ‘yes’.”
There is also the impact of clinical trials on their families. Patients may not want to burden their families and will choose whatever is easiest for their families even if it may not be the best for them.
Everyone agreed that communication and education were essential in overcoming the fear-based patient and family barriers to clinical trials. Some specific approaches, mostly focused on healthcare professionals’ involvement, included the following:
• Provide all the treatment options, including eligible clinical trials, to the patients and their families. Involve them in the decision making.
• Have everyone involved in the conversation, both the patient and close family members.
• Provide education on clinical trials so they know that it is a type of treatment rather than a placebo.
• Include all healthcare professionals in discussing clinical trials: nurses, social workers, primary care providers, surgeons, oncologists, and others.
• Have a dedicated research nurse to explain the clinical trials in depth.
• Utilize various types of media to educate patients regarding clinical trials including advertisements, Facebook, Twitter, and word of mouth.
• Develop relationships in the community by providing specific outreach and education to minority populations.
• Have a process for informed consent that includes the ability to address potential language barriers.
When addressing the cost concerns of the patients and families, the interviewees recommended the following:
• Connect patients to financial counselors or social workers to identify resources. Once they are off of a trial, treatment resources are often available by contacting the drug company directly.
• In partnership with private foundations, set up patient assistance programs in coordination with local hotels and businesses to help with travel expenses.
• With Institutional Review Board approval, provide reimbursement from the trial for some travel expenses, including food, lodging, and transportation.
• Write letters and advocate for patients to insurance companies.
• Encourage patient participation in the Health Insurance Exchange Marketplace
Healthcare Professional Barriers
Lack of time was the most common barrier noted for healthcare professionals. As Neumayer emphasized, “Time is number 1-10, particularly when we are asked to see so many patients, get them through more quickly and are pushed and pulled in so many directions. Number 11 is remembering and 12 is identifying the appropriate patients.”
Related to time was a lack of knowledge and ability to keep up with all the trials that might be appropriate for patients. Despite being aware of latest trials, in the midst of caring for patients, it becomes difficult to remember specific inclusion and exclusion criteria.
Lack of funding prevents institutions from hiring clinical trial coordinators who can provide guidance and chart reviews on identifying appropriate patients for clinical trials and communicating that information to the clinician.
There is no reimbursement to clinicians for clinical trials work, and since it takes a lot of time to discuss clinical trials with patients, there are negative financial implications for physicians. Fear among healthcare professionals was mentioned several times during the discussions. One fear, particularly seen among nurses, was of the unknown impact of treatment and the concern that the patient might not receive the best treatment possible. Another fear, particularly from community oncologists, was that they would lose their patients if they recommended participation in a clinical trial.
To address the lack of time and coordination barriers, have a dedicated research nurse, clinical trials coordinator or clinical trials patient navigator who:
• Focuses on keeping up with the latest clinical trials
• Reviews the patients’ charts and types of cancers (prescreening)
• Identifies which patients would be eligible for particular trials
• Advises the physician to talk about certain clinical trials
• Coordinates the process.
• Talks with patients about clinical trials
Fostering communication and collaboration across researchers, nurses, physicians, and community oncologists increases knowledge of clinical trials and addresses some of the fear and cost concerns. Some practical ways to encourage this collaboration include:
• Meet periodically with researchers, physicians and community oncologists to share what clinical trials are available for patients
• Create opportunities to listen to the concerns of specific healthcare professionals—nurses, social workers, community oncologists, and other physicians—provide opportunities
for discussion and ways to address their concerns
• Involve as many healthcare professionals as possible in discussing clinical trials at every opportunity
• Open trials in collaboration with community oncologists
• Develop communication pieces (newsletters, etc) on current clinical trials for nurses, community oncologists and other physicians
• Attend professional events and create opportunities to discuss clinical trials
• Require a percentage of continuing education credits focused on clinical trials
• Set goals, both individually and collectively, for clinical trial recruitment
• Celebrate successes and provide positive feedback
Healthcare Systems Barriers
Most of the healthcare system barriers focused on funding, coordination and insurance coverage. The funding barriers included the limited funding for clinical trial research, particularly from national research organizations and lack of health system-level resources. Even when there is funding, it may be insufficient to be able to design the trial that would best test the treatment modalities.
Funding is also targeted to particular types of cancers that may be disproportional to the disease burden. Many trials remain open and recruit a minimum number of patients, which can be extremely expensive.2
As Mullett explained, “Clinical trials are expensive, they disrupt the flow of clinical care, they require extra personnel and there are potential risks involved. Those in the ivory tower want us to take care of patients efficiently—and bill for it…there is just no way to justify the costs so there has to be a commitment from the enterprise that they are willing to take a loss on it.”
Connected to the funding barrier is the lack of coordination as well as the requirement of significant documentation. There is often no easy way to find out which patients are eligible for what trials. If the facility or system has not funded a clinical trials coordinator, and there is minimal infrastructure provided, then it is difficult to get all the healthcare professionals working together on clinical trials.
There were varying responses related to the insurance component. Some of the interviewees had frequent challenges with insurance plans not covering care outside of their system or facility even though the system or facility didn’t have the treatment options available to the patient. Others found that those with insurance had adequate coverage for standard of care. They all had concerns about the uninsured, and although some of them were often able to eventually find resources to support their care, uninsured patients sometimes delayed their treatment several months.
The interviewees were hopeful that the Affordable Care Act would have a positive impact on reducing the insurance barrier.
These 6 healthcare professionals provided several recommendations to improve the healthcare system’s ability to recruit and conduct clinical trials. The following focused on addressing
the funding issues:
• Work together as an organization to advocate to legislative bodies for additional funding
• Collaborate with cancer center fundraising efforts to support clinical trials
• Identify private foundations interested in supporting clinical trials
• Support many different types of clinical trials from industry-supported, which often have adequate funding, to cooperative and investigator initiated ones
• Recognize the importance and support clinical trials with personnel, office space, and resources to achieve clinical trial goals
• Consider the clinician support and system capacity prior to conducting trials. Only conduct trials that would be most cost effective, with responsible conduct and good clinical practice
There were also several recommendations related to coordination challenges:
• Encourage healthcare system leaders to begin the conversation about clinical trials in order to promote positive publicity and raise awareness among cancer patients and communities
• Invest in at least 1 person dedicated to being a clinical trials coordinator/expert within the healthcare organization
• Ensure that new technologies, such as electronic medical records, will support clinical trials efforts
• Combine practices to create bigger networks that would support clinical trials
• Include clinical trial participation metrics into dashboards and other measures of performance
Although it may take time for a healthcare organization to implement these best practices, a priority consistently recommended by all 6 healthcare professionals included having a dedicated clinical trials person. As Byrne said, “There is agreement that it is important to have one person dedicated to being a clinical trials expert—a research nurse—where all she does is
talk with patients about clinical trials, knows what trials are available and coordinates the process.”
1. Murthy VH, Krumholz HM, Gross CP. Participation in cancer clinical trials: Race-, sex-, and age-based disparities. JAMA. 2004;291(22):2720–2726. doi:10.1001/jama.291.22.2720.
2. Green L. One in five cancer trials end too early, but GU studies not more likely. http://www.onclive.com/conference-coverage/gu-2014/One-in-Five-Cancer-Trials-End-Too-Earlybut-GU-Studies-Not-More-Likely. Published January 28, 2014. Accessed February 6, 2014.
3. American Society of Clinical Oncology. Insurance coverage for clinical trial participants. http://www.asco.org/practice-research/insurance-coverage-clinical-trial-participants?et_cid=33233356&et_rid=619104094&linkid =http%3a%2f%2fwww.asco.org%2fpracticeresearch%2finsurance-coverage-clinical-trial-participants. Accessed February 4, 2014.