AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. May 2014, Volume 16, Number 5: 365-368.

Policy Forum

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The Exclusion of Older People from Participation in Cardiovascular Trials

Elderly persons should not be excluded from participation in clinical trials for cardiovascular drugs since that population comprises the largest number of patients with cardiovascular disease.

Jerry H. Gurwitz, MD

According to the US Food and Drug Administration (FDA), “Patients included in clinical studies should reflect the population that will receive the drug when it is marketed…. There is no good basis for the exclusion of patients [from participation in clinical trials] on the basis of advanced age alone…. If a drug will be used in conditions where specific concomitant diseases are likely to be present, an attempt should be made to include in the treatment population patients with other diseases” [1]. These principles were highlighted by the FDA in a 1989 guideline for the study of drugs likely to be used in the elderly. Unfortunately, that guideline has largely been a failure, and the profound lack of evidence to guide clinical decision making in the care of older adults presents mounting challenges for US physicians, patients, and families as the nearly 80 million baby boomers age into their geriatric years.

In 1992, Nanette Wenger wrote that “the profile of cardiovascular illness in the United States has shifted to encompass predominantly elderly populations…yet it is precisely in this population that the traditional exclusion, or at best underrepresentation, of elderly persons in clinical trials has generated an information void” [2]. A pattern of exclusion of elderly persons from participation in cardiovascular clinical trials has been apparent since the first large randomized clinical trials were conducted in the 1960s [3-5]. For example, the vast majority of patients with heart failure are older than 65 years of age [6], yet Masoudi and colleagues have described a “voltage drop” in eligibility of older subjects in studies of treatment for heart failure [7]. More than 40 percent of Medicare beneficiaries who survive hospitalization for heart failure would have been deemed ineligible for participation in the landmark studies of left ventricular dysfunction trial and the Metoprolol controlled release/extended release intervention trial in congestive heart failure merely on the basis of age [7].

More recently, Cherubini and colleagues examined data from ongoing heart failure studies in the World Health Organization Clinical Trials Registry.[8] These investigators assessed the proportion of trials that excluded patients according to an arbitrary upper age limit or by criteria that might indirectly limit the participation of older persons. Of 251 trials, more than a quarter excluded patients based on an arbitrary age limit. Overall 109 trials (43 percent) had one or more poorly justified exclusion criteria that could limit the participation of older study subjects. Poorly justified criteria included comorbidity described in a non-specific manner, use of medications that would not impact the study protocol, and visual and hearing impairment that would not lead to safety concerns.

The resulting paucity of relevant clinical evidence worsens a quandary faced by physicians in making clinical decisions in providing care to older patients. Physicians struggle with the dilemma, on the one hand, of using treatments that may not be beneficial and that could cause harm to a patient or, on the other, denying effective treatments to patients at high risk for dying who could benefit from more aggressive management [9]. The ethical principle of beneficence requires that a clinician follow two general rules. The first is to “do no harm” (nonmaleficence), and the second is to “maximize possible benefits and minimize possible harms” [10]. According to Pantilat, “Physicians should not provide ineffective treatments to patients, as these offer risk with no possibility of benefit and thus have a chance of harming patients. In addition, physicians must not do anything that would purposely harm patients without the action being balanced by proportional benefit” [11].

Physicians also have an ethical responsibility to use resources wisely. Tilburt and Cassel have called this “parsimonious medicine”—the delivery of care that fits the needs and circumstances of patients and avoids wasteful care that does not benefit them [12]. Parsimonious medicine should not be considered rationing, which is the “explicit or implicit withholding and allocation of beneficial resources from some patients for the sake of others” [13] Physicians must be stewards of health care resources, and they have an ethical obligation to employ them wisely [14]. High-quality evidence is required to fulfill this important responsibility.

Clearly, a multifaceted approach is required to improve the evidence base to guide the care of older patients with cardiovascular disease. Some possible initial steps include [15]:

  • Eliminating arbitrary age-based exclusions in cardiovascular clinical trials;
  • Requiring strong justification for exclusion criteria, including those relating to comorbidity, medication use, and functional and cognitive impairment, that affect the inclusion of older people;
  • Encouraging clinical trials specific to older individuals through targeted federal funding;
  • Publicizing trends in the inclusion of elderly patients in cardiovascular clinical trials to assess progress in improving the generalizability of research findings to this high-risk population; and
  • Requiring direct evidence of benefit in making national coverage determinations regarding services for Medicare beneficiaries, which would serve as a powerful incentive to enhance the participation of older persons in clinical trials [16].

There will always be uncertainties regarding the risks and benefits of a particular therapy or intervention in an individual patient. Yet as Lowenthal and colleagues have written [17], it is essential to gather reliable evidence through RCTs “to inform the care of future patients, the fairness of present and future access [to effective therapies], and the value of stewardship of limited resources” [18].



References

  1. US Food and Drug Administration Center for Drug Evaluation and Research. Guideline for the study of drugs likely to be used in the elderly. Rockville, MD.: Food and Drug Administration. 1989; 6. http://www.fda.gov/downloads/Drugs/ GuidanceComplianceRegulatoryInformation/ Guidances/ucm072048.pdf. Accessed March 21, 2014.
  2. Wenger NK, ed. Inclusion of Elderly Individuals in Clinical Trials: Cardiovascular Disease and Cardiovascular Therapy as a Model. Kansas City, MO: Marion Merrell Dow Inc; 1993:293.
  3. Gurwitz JH, Col NF, Avorn J. The exclusion of the elderly and women from clinical trials in acute myocardial infarction. JAMA. 1992;268(11):1417-1422.
  4. Lee PY, Alexander KP, Hammill BG, Pasquali SK, Peterson ED. Representation of elderly persons and women in published randomized trials of acute coronary syndromes. JAMA. 2001;286(6):708-713.
  5. Dodd KS, Saczynski JS, Zhao Y, Goldberg RJ, Gurwitz JH. Exclusion of older adults and women from recent trials of acute coronary syndromes. J Am Geriatr Soc. 2011;59(3):506-511.
  6. Gurwitz JH, Magid DJ, Smith DH, et al. Contemporary prevalence and correlates of incident heart failure with preserved ejection fraction. Am J Med. 2013;126(5):393-400.
  7. Masoudi FA, Havranek EP, Wolfe P, et al. Most hospitalized older persons do not meet the enrollment criteria for clinical trials in heart failure. Am Heart J. 2003;146(2):250-257.
  8. Cherubini A, Oristrell J, Pla X, et al. The persistent exclusion of older patients from ongoing clinical trials regarding heart failure. Arch Intern Med. 2011;171(6): 550-556.
  9. Lee DS, Tu JV, Juurlink DN, et al. Risk-treatment mismatch in the pharmacotherapy of heart failure. JAMA. 2005;294(10):1240-1247.
  10. Yale Human Subject Research Resource and Education Program. Introduction/ethical overview: beneficence. http://learn.yale.edu/hsp/module_1/ 3_beneficence.asp. Accessed January 3, 2014.
  11. Pantilat S. Beneficence vs. nonmaleficence. http://missinglink.ucsf.edu/lm/ ethics/content%20pages/ fast_fact_bene_nonmal.htm. Accessed January 3, 2014.
  12. Tilburt JC, Cassel CK. Why the ethics of parsimonious medicine is not the ethics of rationing. JAMA. 2013;309(8):773-774.
  13. Tilburt and Cassel, 773.
  14. Choosing Wisely website. http://www.choosingwisely.org/. Accessed January 3, 2014.
  15. Gurwitz JH, Goldberg RJ. Age-based exclusions from cardiovascular clinical trials: implications for elderly individuals (and for all of us). Comment on “The persistent exclusion of older patients from ongoing clinical trials regarding heart failure.” Arch Intern Med. 2011;171(6):557-558.
  16. Dhruva SS, Redberg RF. Variations between clinical trial participants and Medicare beneficiaries in evidence used for Medicare national coverage decisions. Arch Intern Med. 2008;168(2):136-140.
  17. Lowenthal J, Hull SC, Pearson SD. The ethics of early evidence—preparing for a possible breakthrough in Alzheimer’s disease. N Engl J Med. 2012;367(6):488-490.
  18. Lowenthal, Hull, and Pearson, 489.

Jerry H. Gurwitz, MD, is chief of the Division of Geriatric Medicine and the Dr. John Meyers Professor of Primary Care Medicine at the University of Massachusetts Medical School in Worcester. He is executive director of the Meyers Primary Care Institute, a joint endeavor of Reliant Medical Group, Fallon Community Health Plan, and the University of Massachusetts Medical School whose mission is to improve the health of vulnerable populations through innovative research and educational initiatives.

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