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Incentives - Not Just For Business Anymore

David L. Graham, MD

11 Jan 2013 12:25 AM

There is a lot we do not learn in medical school. Much of that added education comes when you rise to a position of management or governance in a practice. Plenty of business publications will tell you that you get the activity you incent for. Many times we do not recognize what the true incentives are. It can be interesting to trace an unexpected behavior to the previously unrecognized incentive.

We have struggled with the difficulty of increasing enrollment onto clinical trials for years. We know having a physician willing to be active in clinical research is one of the major factors. Physician incentives to clinical research participation have been long debated. What has not been discussed, as much, are patient incentives or disincentives to clinical trial participation. Thinking about a patient’s influences means separating where the patient is being seen. Are they being seen at a “home” practice or have they traveled to be seen at a distant site or “destination” practice. To be clear, it does not matter if “home” practice is an academic or community practice. The determining factor is where the practice is located.

A patient being seen at a “home” practice has their usual pressures and stressors affecting them over and above those stressors associated with having cancer. When they come for their appointments they are taking hours off work (as opposed to days or weeks as will be discussed later). They are thinking, consciously or subconsciously, about how this is going to impact their jobs. When we ask them to consider a trial, we ask them for more hours of their time. Time is needed to be taught the trials, to potentially undergo testing that wouldn’t otherwise be performed, and to keep personal records for quality-of-life analysis or medication adherence that would not otherwise be required. ASCO’s new Chief Medical Officer, Dr. Richard Schilsky, discussed this as far back as 2003 in the web publication, Conversations in Care.

What influences or incentives impact that patient who has traveled to be seen? Admittedly we are immediately dealing with a self-selected population. They are seeking something else that they do not feel they can get at home. When they have traveled to Mayo or to MD Anderson or to any of the other major clinics that are a destination for care, they are under a different mind-set. They are planning on being there for days if not longer. They are not worried about getting to work tomorrow, getting home to cook dinner, or any of the other seemingly mundane parts of our daily lives. If they are asked to spend extra time learning about a trial or undergoing further testing, that is simply considered a value-added part of the care. What throws a hitch into the process, however, is being asked to undergo the treatment associated with the trial at that institution.

I make no claims that these are the only factors at play. We still have plenty to learn before we can impact clinical trial enrollment. Anything we can ethically do to influence trial enrollment can only be helpful. Cooperative group trials can allow patients seen at the “destination” practices to be treated at “home.” Those single institution trials are more problematic, especially those involving new drugs. At this time, regulatory requirements pertaining to the tracking of the drugs preclude those therapies being given at “home.” Modifications in those regulations could potentially be an opportunity. A relaxed, informal, “spit-balling” session could certainly come up with other ideas to consider. As we look to improve trial enrollment, we cannot see one change, one plan, one tactic that will be the grand fix. It has been and will continue to be a series of small changes that can add up to a grand effect.


Number of Comments: 1
Michael A. Thompson, MD, PhD

Friday, January 11, 2013 11:47 AM

Amen brother.

While many areas could be addressed, I like the concept of "Just in time" clinical trial activation to allow rapid local opening of studies for less common diseases.  
This will be of particular importance as studies become more biomarker driven (= smaller populations) and travel and lodging becomes more expensive.

Great post.


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David L. Graham, MD