Unit V



 Regulations in clinical research

ICH-GCP

Clinical studies should be carried out according to International Conference on Harmonisation (ICH) / WHO Good Clinical Practice standards. This provides a unified standard for the European Union (EU), Japan, and the United States, as well as those of Australia, Canada, the Nordic countries and the World Health Organisation (WHO). Thus, any country that adopts this guideline technically follows this same standard.
I have gathered some links which you may find useful if you plan to do clinical research.
The International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use (ICH) is a unique project that brings together the regulatory authorities of Europe, Japan and the United States and experts from the pharmaceutical industry in the three regions to discuss scientific and technical aspects of product registration.
The purpose is to make recommendations on ways to achieve greater harmonisation in the interpretation and application of technical guidelines and requirements for product registration in order to reduce or obviate the need to duplicate the testing carried out during the research and development of new medicines. The objective of such harmonisation is a more economical use of human, animal and material resources, and the elimination of unnecessary delay in the global development and availability of new medicines whilst maintaining safeguards on quality, safety and efficacy, and regulatory obligations to protect public health. This Mission is embodied in the Terms of Reference of ICH.
The main task of the EMEA is to
·         Provide the Member States and the Community institutions with the best possible scientific advice on questions concerning quality, safety and efficacy of medicinal products for human and veterinary use.
·         Establish a multinational scientific expertise through the mobilisation of existing national resources in order to achieve a single evaluation via a centralised or decentralised marketing authorisation system.
·         Organise speedy, transparent and efficient procedures for the authorisation, surveillance and, where appropriate, withdrawal of products in the European Union.
·         Advise companies on the conduct of pharmaceutical research.
·         Reinforce the supervision of existing medicinal products in coordinating national pharmacovigilance and inspection activities.
·         Create the necessary databases and telecommunication facilities to promote a more rational drug use.


The mission of FDA's Center for Drug Evaluation and Research is to assure that safe and effective drugs are available to the American people. The information below provides an understanding of how CDER works to accomplish this mission as it relates to new drug development and review. See the CDER Handbook.
·         New Drug Development Process- An interactive chart that provides an overview of the new drug development process, with an emphasis on preclinical research and clinical studies conducted by the drug's sponsor.
·         Investigational New Drug (IND) Review Process- An interactive chart that provides an overview of CDER's investigational new drug application process, including how CDER determines if the product is suitable for use in clinical trials.
·         New Drug Application (NDA) Review Process- An interactive chart that provides an overview of CDER's new drug application review process, including how CDER determines the benefit:risk profile of a drug product prior to approval for marketing.


OHSR operates within the Office of the Deputy Director for Intramural Research (DDIR), National Institutes of Health (NIH). The NIH is part of the U.S. Public Health Service (PHS) which is, in turn, an agency within the Department of Health and Human Services (DHHS). The OHSR was established to help IRP investigators understand and comply with the ethical guidelines and regulatory requirements for research involving human subjects. OHSR's overall goal is to promote and support the IRP's efforts to conduct innovative research which protects the rights and promotes the welfare of human subjects. Have a look at the following sites.
·         Belmont Report
·         Nuremberg Code
·         Department of Health and Human Services (DHHS) regulations for the protection
of human subjects, 45 CFR 46



This document sets out the objectives of Standard Operating Procedures and defines the Investigators' responsibilities when undertaking a clinical study supported by TDR. It provides instructions for planning, performing, documenting and reporting clinical studies, and also provides a useful glossary of terms.
(Ref: http://www.vadscorner.com/internet29.html)

 The purpose of audits

An audit is the examination of the financial report of an organisation - as presented in the annual report - by someone independent of that organisation. The financial report includes a balance sheet, an income statement, a statement of changes in equity, a cash flow statement, and notes comprising a summary of significant accounting policies and other explanatory notes.

The purpose of an audit is to form a view on whether the information presented in the financial report, taken as a whole, reflects the financial position of the organisation at a given date, for example:
Are details of what is owned and what the organisation owes properly recorded in the balance sheet?
Are profits or losses properly assessed?
When examining the financial report, auditors must follow auditing standards which are set by a government body. Once auditors have completed their work, they write an audit report, explaining what they have done and giving an opinion drawn from their work. With some exceptions, all organisations subject to the Corporations Act must have an audit each year. Other organisations may require or request an audit depending on their structure and ownership or for a special purpose.

What don't auditors do?

Audit other information provided to the members of the organisation, for example, the directors' report.

Check every figure in the financial report – audits are based on selective testing only.
Judge the appropriateness of the organisation's business activities or strategies or decisions made by the directors.
Look at every transaction carried out by the organisation.
Test the adequacy of all of the organisation's internal controls.
Comment to shareholders on the quality of directors and management, the quality of corporate governance or the quality of the organisation's risk management procedures and controls.

What can't auditors do?

Predict the future – The audit relates to a specific past accounting period. It does not judge what may happen in the future, and so cannot provide assurance that the organisation will continue in business indefinitely.
Be there all the time – The audit is carried out during a defined timeframe, and auditors are not at the organisation all the time. The prime purpose of the audit is to form an opinion on the information in the financial report taken as a whole, and not to identify all possible irregularities. This means that although auditors are on the look-out for signs of potential material fraud, it is not possible to be certain that frauds will be identified.

How is the audit conducted?

The organisation's management prepares the financial report. It must be prepared in accordance with legal requirements and financial reporting standards.
The organisation's directors approve the financial report.
Auditors start their examination by gaining an understanding of the organisation's activities, and considering the economic and industry issues that might have affected the business during the reporting period.
For each major activity listed in the financial report, auditors identify and assess any risks which could have a significant impact on the financial position or financial performance, and also some of the measures (called internal controls) that the organisation has put in place to mitigate those risks.
Based on the risks and controls identified, auditors consider what management does has done to ensure the financial report is accurate, and examine supporting evidence.
Auditors then make a judgement as to whether the financial report taken as a whole presents a true and fair view of the financial results and position of the organisation and its cash flows, and is in compliance with financial reporting standards and, if applicable, the Corporations Act.
Finally, auditors prepare an audit report setting out their opinion, for the organisation's shareholders or members.

What do auditors do, specifically?

Auditors discuss the scope of the audit work with the organisation – the directors or management may request that additional procedures be performed. Auditors maintain independence from management and directors so that tests and judgments are made objectively. Auditors determine the type and extent of the audit procedures they will perform, depending on the risks and controls they have identified. The procedures may include: asking a range of questions - from formal written questions, to informal oral questions - of a range of individuals at the organisation
examining financial and accounting records, other documents, and tangible items such as plant and equipment making judgments on significant estimates or assumptions that management made when they prepared the financial report obtaining written confirmations of certain matters, for eg, asking a debtor to confirm the amount of their debt with the organization testing some of the organisation's internal controls watching certain processes or procedures being performed.

Clinical audit is a process that has been defined as "a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change".
The key component of clinical audit is that performance is reviewed (or audited) to ensure that what should be done is being done, and if not it provides a framework to enable improvements to be made. It had been formally incorporated in the healthcare systems of a number of countries, for instance in 1993 into the United Kingdom's National Health Service (NHS), and within the NHS there is a clinical audit guidance group in the UK.

One of first ever clinical audits was undertaken by Florence Nightingale during the Crimean War of 1853-1855. On arrival at the medical barracks hospital in Scutari in 1854, Nightingale was appalled by the unsanitary conditions and high mortality rates among injured or ill soldiers. She and her team of 38 nurses applied strict sanitary routines and standards of hygiene to the hospital and equipment; in addition, Nightingale had a talent for mathematics and statistics, and she and her staff kept meticulous records of the mortality rates among the hospital patients. Following these changes the mortality rates fell from 40% to 2%, and the results were instrumental in overcoming the resistance of the British doctors and officers to Nightingale's procedures. Her methodical approach, as well as the emphasis on uniformity and comparability of the results of health care, is recognised as one of the earliest programs of outcomes management.

Another notable figure who advocated clinical audit was Ernest Codman (1869–1940). Codman became known as the first true medical auditor following his work in 1912 on monitoring surgical outcomes. Codman's "end result idea" was to follow every patient's case history after surgery to identify errors made by individual surgeons' on specific patients. Although his work is often neglected in the history of health care assessment, Codman's work anticipated contemporary approaches to quality monitoring and assurance, establishing accountability, and allocating and managing resources efficiently.

Whilst Codman's 'clinical' approach is in contrast with Nightingale's more 'epidemiological' audits, these two methods serve to highlight the different methodologies that can be used in the process of improvement to patient outcome.


Types of audits

  1. Standards-based audit - A cycle which involves defining standards, collecting data to measure current practice against those standards, and implementing any changes deemed necessary.
  2. Adverse occurrence screening and critical incident monitoring - This is often used to peer review cases which have caused concern or from which there was an unexpected outcome. The multidisciplinary team discusses individual anonymous cases to reflect upon the way the team functioned and to learn for the future. In the primary care setting, this is described as a 'significant event audit'.

  1. Peer review - An assessment of the quality of care provided by a clinical team with a view to improving clinical care. Individual cases are discussed by peers to determine, with the benefit of hindsight, whether the best care was given. This is similar to the method described above, but might include 'interesting' or 'unusual' cases rather than problematic ones. Unfortunately, recommendations made from these reviews are often not pursued as there is no systematic method to follow.
  2. Patient surveys and focus groups - These are methods used to obtain users' views about the quality of care they have received. Surveys carried out for their own sake are often meaningless, but when they are undertaken to collect data they can be extremely productive.
Clinical audit comes under the Clinical Governance umbrella and forms part of the system for improving the standard of clinical practice.
Clinical Governance is a system through which NHS organisations are accountable for continuously improving the quality of services; it ensures that there are clean lines of accountability within NHS trusts and that there is a comprehensive programme of quality improvement systems. The six pillars of clinical governance are:
·         Clinical Effectiveness
·         Research & Development
·         Openness
·         Risk Management
·         Education & Training
·         Clinical Audit
Clinical audit was incorporated within Clinical Governance in the 1997 White Paper, "The New NHS : Modern, Dependable", which brought together disparate service improvement processes and formally established them into a coherent Clinical Governance framework.


Preparing for audits.

In the mid-1950s, the National Cancer Institute (NCI; Bethesda, Maryland) began funding the Cooperative Group Program. Throughout the next 25 years, there was no on-site verification of protocol compliance and validation of the data submitted by participating members of these cooperative groups. In contrast, the US Food and Drug Administration (FDA; Washington, DC) required that pharmaceutical companies perform on-site validation of the clinical trial data involving testing of investigational new drugs. In 1979, it was discovered that scientific fraud had occurred at one institution1 that was a prominent member of a major NCI-funded cooperative group. As a result of that event, in 1981 the NCI implemented a requirement that all entities funded by the NCI must have a system in place for on-site auditing of clinical trial data and protocol compliance. Verification of administrative requirements, such as oversight by an institutional review board (IRB) and documentation of written informed consent, was also implemented as part of this auditing process.

Over the subsequent 25 years, the process has been refined and supplemented with additional requirements such as the auditing of consent form contents and the handling of investigational drugs in institutional pharmacies. Audits by various entities (the NCI, the FDA, pharmaceutical firms, etc) are a fact of life,2 and fortunately, the process has rarely uncovered instances of scientific fraud. The more important benefit of auditing is that the scrutiny applied by external review of those involved in clinical investigation often results in better compliance with trial requirements and greater accuracy in data collection, to the benefit of all clinical research. Audits also serve as a hands-on educational process for both physicians as well as clinical research associates (CRAs), both when being audited and when invited to be the auditor at another site in their cooperative group.

The announcement that an audit will be conducted in the near future always creates dread and anxiety in those persons to be visited, especially in those closest to the data collection process—the CRAs. In this article, we provide some hints for audit preparation and ways to avoid deficiencies. We draw on our experience with the Cancer and Leukemia Group B (CALGB) audit process for our frequently asked questions. Because all NCI-funded cooperative groups have similar audit programs, the information can be generalized for any such audits, though there may be minor variations depending on the cooperative group involved.

What areas will be audited?

A document that should be part of the training of all new CRAs and all clinical investigators is the Audit Guidelines of the NCI Clinical Trials Monitoring Branch.3 This document provides the standards that all cooperative group auditors must follow. When an audit is scheduled, a review of this document will help the site staff understand what items will be reviewed and how deficiencies will be assessed and graded. There are three main areas of review: (1) IRB oversight and consent contents; (2) handling of investigational drugs, including a visit to the pharmacy; and (3) patient case review. In the latter, there are six subcategories of review: (1) consent form signing, dating, and filling in blanks; (2) protocol eligibility; (3) protocol-directed treatment, including (when applicable) compliance with radiation therapy and surgery technique; (4) verification of treatment response (or lack thereof) and patient outcome; (5) toxicity grading and recording; and (6) accuracy of data recording and submission, and the fulfillment of special requirements (when applicable) such as submission of blood or urine samples, quality-of-life questionnaires, pathology specimens, etc.

Which patients and studies will be audited?

This varies with each cooperative group, but the NCI requires review of at least several studies involving investigational drugs, and studies representing a cross-section of protocols on which the site has enrolled patients. In the CALGB, an effort is also made to include at least one patient entered by each participating physician at the site, and to include some studies involving complex treatments (such as for acute leukemia) and combined-modality treatment.

Is there any source of information regarding audit preparation?

Each cooperative group maintains a set of policies regarding how audits are conducted, all in accordance with the NCI Audit Guidelines. In the CALGB, there is discussion of audit preparation at CRA workshops, and once yearly at the main group meeting, an “Audit Preparation Workshop” is held. The slide presentations for this workshop are also available to group members on the CALGB Web site. Other groups have similar training sessions for both group members to be audited and those who will be conducting an audit.

What physical facilities and staff should be arranged?

Depending on the size of the audit team, a room should be reserved that is large enough for the team and the local staff. At a few CALGB audits, only a desk and chair in an office have been set aside for a team of six people, which is obviously insufficient. A CRA experienced with both the case report forms and the local medical records should be immediately available to assist in finding items to be reviewed and answering questions the auditors may have. Some cooperative groups do not want any local staff on hand during an audit, but at CALGB audits, a local staff person is required to stay with the audit team all day. A senior physician should also make time available for the exit interview at the end of the audit.

What will be audited regarding the IRB?

All studies on the Audit Patient List will have an assessment of compliance in submitting the protocol to the IRB for initial review, annual renewals (by each 365-day interval since the previous approval), review of all relevant amendments/revisions/updates within the NCI-required 90 days after implementation, and timely submission and review of all reportable local serious adverse events and those broadcast by the relevant group or other research entity (e.g., NCI, pharmaceutical firms). The CALGB auditors have found that contemporaneous updating of such IRB documents with chronological filing in specific loose-leaf binders allows one to be certain that all such items are easy to locate (for both local staff and auditors) and that nothing is missing.

Not only will the studies listed on the Audit Patient List be reviewed for compliance with IRB requirements, but in some groups (including CALGB), several unannounced closed studies are also audited for continued fulfillment of IRB review requirements.

What will be audited regarding consent form contents?

Review of the details of a sample of the local consent forms is required by the NCI. A minimum of three forms must be reviewed, but most sites have a sufficiently large patient accrual so that twice this number are reviewed. Some groups require that the signed consent form be submitted to the group headquarters for review during patient registration. At that time, any deficiencies are identified for correction. Other groups depend on the audit process to monitor compliance with consent form contents. There are many requirements for consent form content specified in Federal government documents, but the NCI requires two items to be identical to the protocol-specific Model Consent Forms (approved by the NCI staff and/or the central IRB before a new study can be activated); they are: (1) all the risks listed in the Model Consent Form must be in the local consent form; none can be omitted; (2) all the alternatives and associated explanations in the Model Consent Form must be present. It is worthwhile to check all local consent forms to be certain such items are not omitted.

One error that occurs commonly is the failure to complete fill-in-the-blank items on a consent form. If the local consent form has additional items such as patient initials on every page, names and phone numbers, and yes/no responses for special items such as blood sample collection, then they must be completed. It is a simple task to be certain that these items are completed at the time a patient signs the original consent form. No patient should be registered until local staff members have verified that all such items have been completed.

What will be reviewed at the pharmacy or other drug preparation site?

Since 1983, the NCI has required that cooperative group audits include a review of the handling of investigational drugs. The Audit Guidelines3 and the NCI Web site4 have information regarding the requirements for such handling, as well as the “Dos and Don'ts.” Others5 have also published guides on preparation for this aspect of audits. The pharmacist should assemble all Drug Accountability Record Forms (DARFs) relevant to the audit and all invoices for all incoming and return shipments, and arrange them in chronological order for auditor review. Someone familiar with the investigational drugs must be available on the day of the audit and plan on meeting with the audit team. In-stock investigational drug supplies should be checked to ensure that the containers are properly labeled as to drug and study, and that the amount of remaining stock corresponds to the figures on the DARF.

The CALGB Pharmacy Committee has prepared a checklist (Table 1)that can be a useful guide for pharmacists in making sure deficiencies are minimized prior to the actual audit. One error seen repeatedly in audits is that excess drug supplies are kept well after they are needed (i.e., the study has closed to new patient accrual and no patients are being treated, or the drug has expired), and only a few days prior to the audit, they are returned to the NCI. The pharmacy staff should have a system in place whereby shelf stocks are assessed on a monthly or quarterly basis, at which time the return of unused drug supplies is accomplished.

How should the local records be prepared for the patient case review?

The work of the auditors is greatly facilitated if the important items regarding protocol compliance and patient management have color-coded adhesive tabs applied for ease of identification. For example, one color would indicate pre-enrollment and eligibility items, another color would indicate each treatment cycle and toxicity assessment, and still another color to represent the salient radiographic reports regarding response, etc. Importantly, each tab must be identified. In some audits, the local staff members have appended such color-coded tabs, but nothing was identified. The local records thus have multiple colored tabs, but without identification, it is still difficult for the auditors to find particular items.

Some institutions now have electronic medical records, and nothing on paper is available for review. In such cases, it is worthwhile to print the most important items for review (e.g., pathology reports, initial physician evaluations, operative reports). The site staff should then have a computer screen available for each auditor or team, with a local staff member sitting adjacent who is qualified to locate items in the system as they are needed. The auditors could then, for example, request the baseline set of blood test results, and they would be immediately brought up on the screen. The same process can be used to review electronic records of radiographs. Computed tomography scans are now recorded on disc and not on film in most hospitals. In the CALGB, the auditors rarely review the normal radiographic studies (e.g., a screening brain magnetic resonance imaging study), but the auditors do want to review the serial scans done on a patient whose assessable tumor is being evaluated for treatment response. Thus, relevant films (or discs) should be made available in such instances. Again, if electronic records are to be reviewed, a qualified local person must be available to assist with the process.

(ref: http://jop.ascopubs.org/content/2/4/157.full)


 Typical audit finding  and How can they be avoided


Informed Consent Process &Documentation
• Accurate and Complete Study Records
• Determination and Documentation that Eligibility
Criteria are Satisfied
• Adverse Event Review and Reporting
• Drug /Devicet Accountability
• Protocol Adherence
• Poor Regulatory Regulatory Site Documentation
• Failure to Address Monitor Findings
• SponsorInvestigator Trials

Informed Consent Process and
Documentation
• Incorrect consent version
• No source documentation of consent process and fact
That subject was provided a copy of consent
• Consent not dated by subject
• Check boxes left blank; pages not initialed by subject
• No HIPAA Authorization
• Original consent missing
• Notreconsented consented when required required
– Long lag time between signed consent and start of
participation


 Accurate and Complete Study Records
Discrepancies between between CRFs and medical
records/source documents
• Incomplete CRFs
• No documentation of PI review of CRFs
• Improper Error Correction
– NO WHITEOUT; NO PENCIL

Determination and Documentation
that Eligibility Criteria are Satisfied

• Eligibility check lists incomplete
• No source documentation confirming eligibility
criteria
• Failure to conduct all tests needed to satisfy
eligibility criteria
• No documentation documentation that PI has reviewed and
signed eligibility checklist
• No documentation of sponsor waiver of eligibility
requirement or waiver by PI when protocol  specifically states that no waivers are allowed

Adverse Event Review and Reporting

• Conflict between CRFs and source
documentation, e.g., AE noted in medical
record but not on CRF, or vice versa
• AEs not signed/graded/attributed in a timely
manner
• Failure to follow reporting requirements

Drug/Device Accountability
• No documentation that oral drug was
provided to subject and/or returned by
subject with pill count
• Poor documentation regarding drug diaries
• Poor prescription practices

 Protocol Adherence
• Changes made in protocol without first
obtaining IRB approval for reasons other than
immediate patient safety
• No documentation of reason for missed tests,
schedule changes, etc.