Will Your Family Make You a Better Trial Participant?

It is becoming increasing accepted within the research community that patient engagement leads to a host of positive outcomes – most importantly (at least practically speaking) improved clinical trial recruitment and retention.

But while we can all agree that "patient engagement is good" in a highly general sense, we don't have much consensus on what the implications of that idea might be. There is precious little hard evidence about how to either attract engaged patients, or how we might effectively turn "regular patients" into "engaged patients".

That latter point - that we could improve trial enrollment and completion rates by converting the (very large) pool of less-engaged patient - is a central tenet of the mHealth movement in clinical trials. Since technology can now accompany us almost anywhere, it would seem that we have an unprecedented opportunity to reach out and connect with current and potential trial participants.

However, there are signs that this promised revolution in patient engagement hasn't come about. From the decline of new apps being downloaded to the startlingly high rate of people abandoning their wearable health devices, there's a growing body of evidence suggesting that we aren't in fact making very good progress towards increasing engagement. We appear to have underestimated the inertia of the disengaged patient.

So what can we do? We know people like their technology, but if they're not using it to engage with their healthcare decisions, we're no better off as a result.

Daniel Calvert, in a recent blog post at Parallel 6 offers an intriguing solution: he suggests we go beyond the patient and engage their wider group of loved ones. By engaging what Calvert calls the Support Circle - those people most likely to "encourage the health and well being of that patient as they undergo a difficult period of their life" - trial teams will find themselves with a more supported, and therefore more engaged, participant, with corresponding benefits to enrollment and retention. 

Calvert outlines a number of potential mechanisms to get spouses, children, and other loved ones involved in the trial process:

During the consent process the patient can invite their support team in with them. A mobile application can be put on their phones enabling encouraging messages, emails, and texts to be sent. Loved ones can see if their companion or family member did indeed take today’s medication or make last Monday’s appointment. Gamification offers badges or pop-ups: “Two months of consecutive appointments attended” or “perfect eDiary log!” Loved ones can see those notifications, like/comment, and constantly encourage the patients. 

Supporting materials can also be included in the Support Circle application. There are a host of unknown terms to patients and their team. Glossaries, videos, FAQs, contact now, and so much more can be made available at their fingertips.

I have to admit I'm fascinated by Calvert's idea. I want him to be right: the picture of supportive, encouraging, loving spouses and children standing by to help a patient get through a clinical trial is an attractive one. So is the idea that they're just waiting for us to include them - all we need to do is a bit of digital communication with them to get them fully on board as members of the study team.

The problem, however, remains: we have absolutely no evidence that this approach will work. There is no data showing that it is superior to other approaches to engage trial patients.

(In fact, we may even have some indirect evidence that it may hinder enrollment: in trials that require active caregiver participation, such as those in Alzheimer's Disease, caregivers are believed to often contribute to the barriers to patient enrollment).

Calvert's idea is a good one, and it's worthy of consideration. More importantly, it's worthy of being rigorously tested against other recruitment and retention approaches. We have a lot of cool new technologies, and even more great ideas - we're not lacking for those. What we're lacking is hard data showing us how these things perform. What we especially need is comparative data showing how new tactics work relative to other approaches.

Over 5 years ago, I wrote a blog post bemoaning the sloppy approaches we take in trial recruitment - a fact made all the more painfully ironic by the massive intellectual rigor of the trials themselves. I'm not at all sure that we've made any real progress in those 5 years.

In my next post, I'll outline what I believe are some of the critical steps we need to take to improve the current situation, and start bringing some solid evidence to the table along with our ideas.

[Photo credit: Flikr user Matthew G, "Love (of technology)"]

Patient Centered Trials - Your Thoughts Needed

The good folks down at eyeforpharma have asked me to write a few blog posts in the run-up to their Patient Centered Clinical Trials conference in Boston this September. In my second article -Buzzword Innovation: The Patient Centricity “Fad” and the Token Patient - I went over some concerns I have regarding the sudden burst of enthusiasm for patient centricity in the clinical trial world.

Apparently, that hit a nerve – in an email, Ulrich Neumann tells me that “your last post elicited quite a few responses in my inbox (varied, some denouncing it as a fad, others strongly protesting the notion, hailing it as the future).”

In preparing my follow up post, I’ve spoken to a couple people on the leading edge of patient engagement:

• Abbe Steel, CEO of HealthiVibe, which is focused on bringing greater patient input into the earliest stages of trial design through focus groups and patient surveys
• Casey Quinlan, co-founder of Patients for Clinical Research, which aims to be a force in patient education and engagement for clinical trials

In addition to their thoughts, eyeforpharma is keenly interested in hearing from more people. They've even posted a survey – from Ulrich:

To get a better idea of what other folks think of the idea, I am sending out a little ad hoc survey. Only 4 questions (so people hopefully do it). Added benefit: There is a massive 50% one-time discount for completed surveys until Friday connected to it as an incentive).

So, here are two things for you to do:

1. Complete the survey and share your thoughts
2. Come to the conference and tell us all exactly what you think

Look forward to seeing you there.

[Conflict of Interest Disclosure: I am attending the Patient Centered Clinical Trials conference. Having everyone saying the same thing at such conferences conflicts with my ability to find them interesting.]

These Words Have (Temporarily) Relocated

Near the end of last year, I had the bright idea of starting a second blog, Placebo Lead-In, to capture a lot of smaller items that I found interesting but wasn't going to work up into a full-blown, 1000 word post.

According to Murphy’s Law, or the Law of Unintended Consequences, or the Law of Biting Off More Than You Can Chew, or some such similar iron rule of the universe, what happened next should have been predictable.

First, my team at CAHG Trials launched a new blog, First Patient In. FPI is dedicated to an open discussion of patient recruitment ideas, and I’m extremely proud of what we've published so far.

Next, I was invited to be a guest blogger for the upcoming Partnerships in Clinical Trials Conference.

Suddenly, I've gone from 1 blog to 4. And while my writing output appears to have increased, it definitely hasn't quadrupled. So this blog has been quiet for a bit too long as a result.

The good news is that the situation is temporary - Partnerships will actually happen at the end of this month. (If you’re going: drop me a line and let’s meet. If you’re not: you really should come and join us!) My contributions to FPI will settle into a monthly post, as I have a fascinating and clever team to handle most of the content.

In case you've missed it, then, here is a brief summary of my posts elsewhere over the past 2 months.

First Patient In

• How to Catalyze a Clinical Trial - My inaugural post introducing the blog and its purpose
• Video: Predicting Referral Conversion in Clinical Trial Advertising - A somewhat technical but very important topic, how to visualize and model the “real time” results of recruitment advertising at the sites.
• The Crystal Ball is on the Fritz - What to do with a broken enrollment feasibility process, and how asking will never be as good as measuring

Partnerships in Clinical Trials

• The New Breed of Clinical Trial Matchmakers - A (hopefully pretty complete, thanks to knowledgeable commenters) listing of services looking to match interested patients to clinical trials
• Rethinking Patient Enrollment, in One Graphic - The perils of predictability in site-based enrollment
• Seize the Data! Will Big Data Save Us from Ourselves? - My take on what I consider to be the large and serious obstacles in the way of “Big Data” solutions for patient recruitment

Please take a look, and I will see you back here soon.

[Photo credit: detour sign via Flikr user crossley]

Patient Recruitment: Taking the Low Road

The Wall Street Journal has an interesting article on the use of “Big Data” to identify and solicit potential clinical trial participants. The premise is that large consumer data aggregators like Experian can target patients with certain diseases through correlations with non-health behavior. Examples given include “a preference for jazz” being associated with arthritis and “shopping online for clothes” being an indicator of obesity.

We've seen this story before.

In this way, allegedly, clinical trial patient recruitment companies can more narrowly target their solicitations* for patients to enroll in clinical trials.

In the spirit of full disclosure, I should mention that I was interviewed by the reporter of this article, although I am not quoted. My comments generally ran along three lines, none of which really fit in with the main storyline of the article:

1. I am highly skeptical that these analyses are actually effective at locating patients
   
2. These methods aren't really new – they’re the same tactics that direct marketers have been using for years
   
3. Most importantly, the clinical trials community can – and should – be moving towards open and collaborative patient engagement. Relying on tactics like consumer data snooping and telemarketing is an enormous step backwards.

The first point is this: certainly some diseases have correlates in the real world, but these correlates tend to be pretty weak, and are therefore unreliable predictors of disease. Maybe it’s true that those struggling with obesity tend to buy more clothes online (I don’t know if it’s true or not – honestly it sounds a bit more like an association built on easy stereotypes than on hard data). But many obese people will not shop online (they will want to be sure the clothes actually fit), and vast numbers of people with low or average BMIs will shop for clothes online.  So the consumer data will tend to have very low predictive value. The claims that liking jazz and owning cats are predictive of having arthritis are even more tenuous. These correlates are going to be several times weaker than basic demographic information like age and gender. And for more complex conditions, these associations fall apart.

Marketers claim to solve this by factoring a complex web of associations through a magical black box – th WSJ article mentions that they “applied a computed algorithm” to flag patients. Having seen behind the curtain on a few of these magic algorithms, I can confidently say that they are underwhelming in their sophistication. Hand-wavy references to Big Data and Algorithms are just the tools used to impress pharma clients. (The down side to that, of course, is that you can’t help but come across as big brotherish – see this coverage from Forbes for a taste of what happens when people accept these claims uncritically.)

But the effectiveness of these data slice-n-dicing activities is perhaps beside the point. They are really just a thin cover for old-fashioned boiler room tactics: direct mail and telemarketing. When I got my first introduction to direct marketing in the 90’s, it was the exact same program – get lead lists from big companies like Experian, then aggressively mail and call until you get a response.

The limited effectiveness and old-school aggressiveness of these programs comes is nicely illustrated in the article by one person’s experience:

Larna Godsey, of Wichita, Kan., says she received a dozen phone calls about a diabetes drug study over the past year from a company that didn't identify itself. Ms. Godsey, 63, doesn't suffer from the disease, but she has researched it on the Internet and donated to diabetes-related causes. "I don't know if it's just a coincidence or if they're somehow getting my information," says Ms. Godsey, who filed a complaint with the FTC this year.

The article notes that one recruitment company, Acurian, has been the subject of over 500 FTC complaints regarding its tactics. It’s clear that Big Data is just the latest buzzword lipstick on the telemarketing pig. And that’s the real shame of it.

We have arrived at an unprecedented opportunity for patients, researchers, and private industry to come together and discuss, as equals, research priorities and goals. Online patient communities like Inspire and PatientsLikeMe have created new mechanisms to share clinical trial opportunities and even create new studies. Dedicated disease advocates have jumped right into the world of clinical research, with groups like the Cystic Fibrosis Foundation and Michael J. Fox Foundation no longer content with raising research funds, but actively leading the design and operations of new studies.

Some – not yet enough – pharmaceutical companies have embraced the opportunity to work more openly and honestly with patient groups. The scandal of stories like this is not the Wizard of Oz histrionics of secret computer algorithms, but that we as an industry continue to take the low road and resort to questionable boiler room tactics.

It’s past time for the entire patient recruitment industry to drop the sleaze and move into the 21st century. I would hope that patient groups and researchers will come together as well to vigorously oppose these kinds of tactics when they encounter them.

(*According to the article, Acurian "has said that calls related to medical studies aren't advertisements as defined by law," so we can agree to call them "solicitations".)