BMJ  2005;331:140-141 (16 July), doi:10.1136/bmj.331.7509.140

Paper

Survey of informed consent for registration of congenital anomalies in Europe

¹ Eurocat Central Registry, London WC1E 7HT, ² Finnish Register of Congenital Malformations, PO Box 220, Helsinki, Finland, ³ Eurocat Central Registry, University of Ulster, Newtownabbey BT37 OQB, ⁴ R&D Office, Health and Social Services in Northern Ireland, Belfast BT2 8BS, ⁵ Northern Netherlands Registry, University of Groningen, Groningen, Netherlands, ⁶ Registry of Congenital Defects in Asturias, Oviedo, Spain, ⁷ Malta Congenital Anomalies Registry, University of Malta, M'Sida, Malta, ⁸ Dublin Registry, Eastern Health Board, Dublin 8, Ireland, ⁹ Antwerp Registry, Provinciaal Instituut voor Hygiene, Antwerpen, Belgium, ¹⁰ Glasgow Registry, Yorkhill Hospital, Glasgow G3 8SJ

Introduction

Eurocat is a network of population based registers of congenital anomalies in Europe covering about a quarter of the birth population in 19 countries (www.eurocat.ulster.ac.uk). We surveyed registries with regard to the requirement for informed consent and its implementation.¹

Participants, methods, and results

We sent a questionnaire on ethics and confidentiality developed by the Eurocat Working Group to 35 registries in 2003 and updated June 2004; 29 registries from 15 countries replied (table). Eight registries reported experience of opt-in informed consent.

View this table: [in this window] [in a new window]   National legislation on informed consent for congenital anomaly and other clinical registers

 

Five registries depend on medical records and notification from clinicians. One experienced a fall in registration (less than 10 written consents in the entire year in which opt-in consent was instituted, compared with 249 cases in the year before opt-in) such that an exemption was negotiated enabling a switch to opt-out consent. Currently 0.1% of parents opt out. A second registry, in which notifying clinicians ask for consent by post, is permitted to keep a reduced, anonymous set of documentation on cases without consent (about 18%). A third registry gives administrative help for clinicians obtaining consent by post (amounting to 1-3 hours a case) but still estimates 15-20% loss of cases through non-response, although only 0.5% of parents actively refuse to participate. A fourth registry is not fully operational because of low notification levels related to the consent requirement. All these registries reported difficulties persuading busy clinicians to undertake the additional work of obtaining consent for the registry, or convincing clinicians of the value of collecting registry data. Healthcare professionals have also to coordinate consent procedures to avoid parents being approached multiple times. A fifth registry does not yet know how ascertainment is affected but reports less than 1% parental refusal.

Of the other three registries operating opt-in consent, one registry covering a small population has research paediatric staff who examine all babies (malformed or not) born in participating hospitals, for which consent is obtained at booking. This registry reports only two parental refusals since 1990. One registry is based on interviews of cases and controls shortly after birth by clinicians who then notify the case to the registry; this registry is not aware of problems, although it has little information from clinicians on parental refusals. One registry is a voluntary association of clinicians who obtain verbal consent from their patients when registering the case and is not aware of serious problems, although this has not been formally evaluated.

Comment

Eurocat experience shows that informed consent is a serious threat to the operation of registries relying on clinician notification or access to medical records. Despite extremely low parental refusal, opt-in informed consent poses logistical problems, as other types of registry have found.^2-4 Although much has been written about the right of the individual to be adequately informed and to give consent (the parents in the cases of newborns), further research should evaluate parents' desire to participate in activities that may lead to the protection of the health of children in the community and the subsequent ethical duty on the part of the clinician to inform and to request consent. However, this places a further burden on clinical workload.⁵

Discussion about opt-in informed consent seems to have eclipsed discussion about effective forms of opt-out consent and also about data confidentiality and research ethics procedures that would be acceptable to the public. The primary concern of most patients is not the use of their data for research but inappropriate access to medical data, and there is insufficient debate about what safe-guards to ensuring confidentiality and the appropriate use of personal data would be sufficient to replace the requirement for individual consent.

What is already known on this topic Although European Directive 95/46/EC allows national law (or a national supervisory body) to exempt healthcare or disease registries from the requirement to obtain informed consent for the processing of personal medical data, many countries have not legislated for any exemptions and there is much debate about the effect of the consent requirement on epidemiological research and surveillance What this study adds The logistical difficulties in obtaining informed consent is a serious threat to the operation of registries that rely on clinician notification or access to medical records, despite extremely low parental refusal Debate about the right of the individual to be adequately informed and to give consent has eclipsed discussion about research governance and confidentiality procedures that might obviate the need for individual consent

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Contributors: All authors are members of the Eurocat Working Group on Ethics and Confidentiality (chair AR; cochair AB) and were involved in the development of the questionnaire and commented on drafts of the paper. AB and HD drafted the paper. AB and NC coordinated data collection. AB analysed the questionnaire data. AR, HDW, IRG, MG, RM, and VN completed questionnaires giving information on ethics and confidentiality in their registries. All authors are guarantors.

Funding: Eurocat is supported by the EU Commission Public Health Directorate Public Health Programme.

Competing interests: None declared.

Ethical approval: All registries have ethical approval appropriate to their national and local ethics guidelines.The following registry leaders or members completed questionnaires giving information on ethics and confidentiality in their registries, and commented on the final draft of the paper: Lenore Abramsky, Neus Baena, Rosa Caballin, Eva Bermejo, Maria-Luisa Martinez Frias, Sebastiano Bianca, Allessandro Bonato, Romano Tenconi, Patricia Boyd, Mary Bythell, Martin Ward Platt, Maria Feijoo, Ester Garne, Blanca Gener, Yves Gillerot, Martin Haeusler, Anna Latos-Bielenska, Ruth Meikle, Isabel Portal Rolland, Carmen Mosquera-Tenreiro, Amanda Neville, Elisa Calzolari, Mary O'Mahoney, Anna Pierini, Fabrizio Bianchi, Annette Queisser-Luft, Gioacchino Scarano, Volker Steinbicker, Claude Stoll, David Tucker, and Diana Wellesley.

References

1. Busby AL, Ritvanen A, Dolk H, Armstrong N, De Walle H, Riaño-Galán I, et al. Informed consent for congenital anomaly registration in Europe. www.eurocat.ulster.ac.uk/pubdata/Publications.html#EUROCAT%20Publications (accessed 5 Jul 2005).
2. Tu JV, Willison DJ, Silver FL, Fang J, Richards JA, Laupacis A, et al. Impracticability of informed consent in the registry of the Canadian stroke network. N Engl J Med 2004;350: 1414-21.[Abstract/Free Full Text]
3. Melton LJ. The threat to medical-records research. N Engl J Med 1997;337: 1466-70.[Free Full Text]
4. Jacobsen SJ, Xia Z, Campion ME, Darby CH, Plevak MF, Seltman KD, et al. Potential effect of authorization bias on medical record research. Mayo Clin Proc 1999;74: 330-8.[Abstract]
5. Verity C, Nicoll A, Manning D. Education and debate: consent, confidentiality, and the threat to public health surveillance. BMJ 2002;324: 1210-3.[Free Full Text]

(Accepted 27 June 2005)

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