Abstract PR-6: Recruiting diverse patients to therapeutic trials: A comparison of three clinical settings

Introduction: The NIH Revitalization Act of 1993 (PL 103-43) mandates inclusion of minorities in clinical research. Research has shown, however, that recruitment of minorities to cancer therapeutic trials remains problematic. Researchers have documented barriers to enrolling minority patients, such as lack of trust in biomedical research, and community-focused outreach and intervention strategies have been examined to address these barriers. There has been less research on the role of cancer clinics in minority recruitment. Policy and sociological research suggest that provider and organizational factors may shape minority recruitment. The health policy literature suggests that provider incentives may play a role in whether clinics actively recruit minorities, and medical sociology suggests that organizational culture might be a factor in whether clinics support minority recruitment activities. Procedures: To explore how provider and organizational factors might impact minority recruitment, we undertook a qualitative research study. To ensure variation with respect to provider incentives and organizational culture, we studied 10 oncology clinics in three different health care delivery settings: academic medical centers, community-based private practices, and public safety-net clinics. We gathered and analyzed data using ethnography, a qualitative research method that documents and interprets the meaning of behavior within the social context in which it takes place. The authors directly observed hundreds of interactions between providers and patients over a period of more than 3 years of ethnographic fieldwork. They also conducted in-depth interviews with providers in each setting. Results: We found that minority recruitment was not well supported in any of the settings we studied. In the academic and private-practice settings, clinic culture supported minority recruitment, but providers had few incentives to seek out and recruit minority patients. As a result, we noted few attempts to recruit diverse patients to trials - an observation consistent with what providers told us in interviews. In the safety-net setting, some providers were motivated by a sense of justice to provide access to trials to their underserved minority patients, but the organizational culture of the safetynet setting failed to support their efforts. In this setting, as well, we found that minority recruitment was relatively uncommon. Conclusions: Provider and organizational factors played a role in minority recruitment in the settings we examined. We found that minority recruitment required an active effort by providers and substantial support from clinics. Given the salience of provider and organizational factors, mandates such as the NIH Revitalization Act may have only limited effect on increasing minority recruitment unless there is institutional support for the implementation of this mandate within individual cancer clinics. In the clinics we studied, key stakeholders have yet to “buy in” to the importance of minority recruitment. Further research in cancer clinics might help better delineate how provider and organizational factors shape recruitment processes and which clinic-focused intervention strategies might improve minority recruitment.