Advancing patient-centered research practices in a pragmatic patient-level randomized clinical trial: A thematic analysis of stakeholder engagement in Emergency Medicine Palliative Care Access (EMPallA)
Authors: Zhao Nicole , Cuthel Allison M. , Storms Owen , Zhang Raina , Yamarik Rebecca Liddicoat , Hill Jacob , Kaur Regina , Van Allen Kaitlyn , Flannery Mara , Chang Alex , Chung Frank , Randhawa Sumeet , Alvarez Isabel Castro , Young-Brinn Angela , Kizzie-Gillett Constance L. , Rosini Dawn , Isaacs Eric D. , Hopkins Ernest , Chan Garrett K. , Booker-Vaughns Juanita , Maguire Margaret , Navarro Martha , Pidatala Neha Reddy , Dunn Patrick , Williams Pluscedia , Galvin Robert , Batra Romilla , Welsh Sally , Vaughan William , Bouillon-Minois Jean-Baptiste , Grudzen Corita R. 
Published: January 2024

Abstract
Background
Involving patient and community stakeholders in clinical trials adds value by ensuring research prioritizes patient goals both in conduct of the study and application of the research. The use of stakeholder committees and their impact on the conduct of a multicenter clinical trial have been underreported clinically and academically. The aim of this study is to describe how Study Advisory Committee (SAC) recommendations were implemented throughout the Emergency Medicine Palliative Care Access (EMPallA) trial. EMPallA is a multi-center, pragmatic two-arm randomized controlled trial (RCT) comparing the effectiveness of nurse-led telephonic case management and specialty, outpatient palliative care of older adults with advanced illness.

Methods
A SAC consisting of 18 individuals, including patients with palliative care experience, members of healthcare organizations, and payers was convened for the EMPallA trial. The SAC engaged in community-based participatory research and assisted in all aspects from study design to dissemination. The SAC met with the research team quarterly and annually from project inception to dissemination. Using meeting notes and recordings we completed a qualitative thematic analysis using an iterative process to develop themes and subthemes to summarize SAC recommendations throughout the project’s duration.

Results
The SAC convened 16 times between 2017 and 2020. Over the course of the project, the SAC provided 41 unique recommendations. Twenty-six of the 41 (63%) recommendations were adapted into formal Institutional Review Board (IRB) study modifications. Recommendations were coded into four major themes: Scientific, Pragmatic, Resource and Dissemination. A majority of the recommendations were related to either the Scientific (46%) or Pragmatic (29%) themes. Recommendations were not mutually exclusive across three study phases: Preparatory, execution and translational. A vast majority (94%) of the recommendations made were related to the execution phase. Major IRB study modifications were made based on their recommendations including data collection of novel dependent variables and expanding recruitment to Spanish-speaking patients.

Conclusions
Our study provides an example of successful integration of a SAC in the conduct of a pragmatic, multi-center RCT. Future trials should engage with SACs in all study phases to ensure trials are relevant, inclusive, patient-focused, and attentive to gaps between health care and patient and family needs.
Trial Registration: Clinicaltrials.gov Identifier: NCT03325985, 10/30/2017.