背景:临床平衡,也被定义为不确定性原理,在招募受试者进行临床试验时被认为是必不可少的。然而,当临床医生受到自己偏好的影响时,平衡就会受到威胁。很少有研究在试验招募的背景下调查平衡。
方法:这项横断面调查征求了临床医生的意见(作为一项针对年轻人的心理干预试验中提供的与治疗有关的11种陈述)。在一项随机对照试验(RCT)中招募有自我伤害或自杀风险的年轻人的道德理由,以评估巴基斯坦的青年文化适应手册辅助心理干预(CMY-AP)。我们将参与Y-CMAPRCT招募的临床医生的观点与未参与试验招募但治疗相似患者的临床医生样本的观点进行了比较。比较他们的社会人口统计学特征和每个群体中同意每个陈述的比例。
结果:有效率为96%(75/78)。调查结果表明,在试验招募期间和RCT结果已知之前,所有响应的临床医生中,大多数(73.3%)认为Y-CMAP是有自我伤害或自杀风险的年轻人的有效治疗方法.尽管人们承认个人对干预的偏好,对于需要进行RCT以达成循证决策,几乎达成共识(90%).然而,招募临床医生报告Y-CMAP治疗偏好的比例与非招募临床医生相比没有显着差异(31(88.6%)与36(90%),p=0.566)。与试验中的(48.5%)相比,非招募临床医生的比例(87.5%)明显更高(p=0.000),表明可能还有其他对患者同样有益的治疗方法。似乎破坏了对干预的偏好。那些报告治疗偏好的人也承认,这种偏好没有任何依据,无论他们多么自信,从而接受临床平衡作为进行RCT的伦理理由。由于年轻患者参与Y-CMAP试验(p=0.015)(即更多未参与试验的临床医生同意这一说法),总体治疗效果更好的观点存在显著差异。同样,更多未参与试验的临床医生认为,对于有自我伤害风险的年轻人而言,其他治疗方案的有效性是一致的(p<0.05).
结论:本文强调,巴基斯坦的临床医生接受临床平衡的概念作为患者参与随机对照试验的伦理理由。临床社区认为进行RCT以产生证据基础和减少偏倚的需求很重要。
BACKGROUND: Clinical equipoise, also defined as the uncertainty principle, is considered essential when recruiting subjects to a clinical trial. However, equipoise is threatened when clinicians are influenced by their own preferences. Little research has investigated equipoise in the context of trial recruitment.
METHODS: This cross-sectional survey sought clinicians\' views (operationalised as 11 statements relating to treatments offered in a trial of a psychological intervention for young people) about equipoise and individual treatment preferences in the context of moral justification for recruiting young people at risk of self-harm or suicide to a randomised controlled trial (RCT) to evaluate the Youth Culturally Adapted Manual Assisted Psychological Intervention (Y-CMAP) in Pakistan. We compared the views of clinicians involved in Y-CMAP RCT recruitment to those of a sample of clinicians not involved in trial recruitment but treating similar patients, comparing their sociodemographic characteristics and the proportions of those in each group agreeing with each statement.
RESULTS: There was a response rate of 96% (75/78). Findings showed that, during trial recruitment and before the RCT results were known, the majority of all responding clinicians (73.3%) considered Y-CMAP to be an effective treatment for young people at risk of self-harm or suicide. Although there was an acknowledgement of individual preferences for the intervention, there was near consensus (90%) on the need to conduct an RCT for reaching an evidence-based decision. However, there were no significant differences in the proportion of recruiting clinicians reporting a treatment preference for Y-CMAP than non-recruiting clinicians (31 (88.6%) versus 36 (90%), p = 0.566). A significantly higher proportion of non-recruiting clinicians (87.5%) as compared to (48.5%) in the trial (p = 0.000) stated that there may be other treatments that may be equally good for the patients, seemingly undermining a preference for the intervention. Those reporting a treatment preference also acknowledged that there was nothing on which this preference was based, however confident they felt about them, thus accepting clinical equipoise as ethical justification for conducting the RCT. There was a significant group difference in views that treatment overall is better as a result of young patients\' participation in the Y-CMAP trial (p = 0.015) (i.e. more clinicians not involved in the trial agreed with this statement). Similarly, more clinicians not involved in the trial agreed on the perceived availability of other treatment options that were good for young people at risk of self-harm (p < 0.05).
CONCLUSIONS: The paper highlights that clinicians in Pakistan accept the notion of clinical equipoise as an ethical justification for patient participation in RCTs. The need for conducting RCTs to generate evidence base and to reduce bias was considered important by the clinical community.