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Addressing Challenges in the Recruitment and Retention of Rare Disease Research Cohorts

Guidance Document, Version 1

Prepared by PCORnet Rare Diseases Task Force

Intent and audience: This guidance document is intended for PCORnet-affiliated researchers who are planning or implementing recruitment and retention activities for PCORnet rare disease research cohorts. The document was collectively written and edited by the inaugural members of the PCORnet Rare Diseases Task Force (RDTF). The content includes expert guidance from the authors and contributors. The information contained in this document is not presumed to be exhaustive, representative, or authoritative. It is envisioned that this document will be updated periodically as new resources and approaches become known. When the document has been approved by PCORI program officers, it will be made available across PCORnet on the Central Desktop. Broader dissemination as part of the NIH Collaboratory Living Textbook for Pragmatic Trials (http://sites.duke.edu/rethinkingclinicaltrials/) can be considered. In addition, this content, plus some description of the PCORnet and the RDTF, might be of interest to rare disease–specific journals (e.g., Orphanet), and if time and interests permit, RDTF members will consider adapting it to a manuscript for submission and review in the future.

Submitted to the PMO 13NOV2014Approved by the PMO 09DEC2014Submitted to PCORI 09Dec2014Comments received by PCORI 03Jan2015Approved by PCORI 20May2015

The Rare Diseases Task Force 1 Overcoming Challenges in Rare Disease Cohorts

http://sites.duke.edu/rethinkingclinicaltrials/

Rare Diseases Task Force

Addressing Challenges in Recruitment and Retention of PCORnet Rare Disease Cohorts

CONTENTSOVERVIEW OF PCORNET..................................................................................................................- 3 -

OVERVIEW OF THE PCORNET RARE DISEASE TASK FORCE.................................................................- 3 -

RECRUITMENT AND RETENTION.......................................................................................................- 4 -

LAYING THE GROUNDWORK.......................................................................................................................- 5 -RECRUITMENT.........................................................................................................................................- 7 -RETENTION........................................................................................................................................... - 10 -REFERENCE LIST..................................................................................................................................... - 12 -

RESOURCES....................................................................................................................................- 13 -


OVERVIEW OF PCORNETPCORnet, the National Patient-Centered Clinical Research Network, is an innovative initiative of the Patient-Centered Outcomes Research Institute (PCORI). The goal of PCORnet is to improve the nation’s capacity to conduct comparative effectiveness research efficiently by creating a large, highly representative network for conducting clinical outcomes research.

PCORnet seeks to transform clinical research by engaging patients, care providers, and health systems in collaborative partnerships to improve healthcare and advance medical knowledge. By bringing research and patient care together, this innovative distributed research network will be able to improve the efficiency with which research that explores the questions that matter most to patients and their families is conducted.

PCORnet will integrate data from multiple Clinical Data Research Networks (CDRNs) and Patient-Powered Research Networks (PPRNs), all selected by and contracted by PCORI. The CDRNs are working to develop the capacity to conduct randomized comparative effectiveness studies using data from clinical practice in a large, defined population. These established or newly developed networks involve two or more healthcare systems, with plans to function as integrated research network. The PPRNs comprise patients and/or caregivers who are motivated to build an ideal network and play an active role in patient-centered comparative effectiveness research (CER). A description of the inaugural networks can be found at http://pcornet.org/member-networks/.

In addition to the CDRNs and PPRNs, PCORnet also includes a Coordinating Center. The major components of the Coordinating Center serving PCORnet include an Executive Leadership Committee, a Program Management Office, and 11 integrated Task Forces covering essential functions. In particular, the Rare Diseases Task Force was established to support CDRNs and PPRNs in identifying populations, developing research priorities, designing, and implementing studies for rare diseases. Please visit www.pcornet.org for additional information.

OVERVIEW OF THE PCORNET RARE DISEASE TASK FORCERare Disease Task Force description: The Phase 1 PCORnet Rare Disease Task Force is comprised of 37 members from more than 26 organizations representing conditions such as (but not limited to) Duchenne and Becker muscular dystrophy, Phelan-McDermid Syndrome, hypothalamic hamartoma, Dravet Syndrome, and tuberous sclerosis, co-infection with HIV and hepatitis C, Hypoplastic left heart syndrome, and amyotrophic lateral sclerosis (ALS). For a complete list of rare disease conditions represented by the Rare Disease Task Force, please refer to pcornet.org.

Co-led by clinicians and researchers with more than 50 years of collective and diverse experience in the rare disease domain, the RDTF members bring perspectives and contribute insight from a variety of experiences such as assessing the needs of rare disease communities, recruiting and retaining research cohorts, and writing protocols and serving in other capacities to advance knowledge needed for the


http://www.pcornet.org/

http://pcornet.org/member-networks/

treatment and management of rare conditions. While some Task Force members are new to the rare disease space, others have more than 20 years of experience in their roles as clinical researchers; biomedical researchers, social scientists; and policy/legal specialists. Additionally, patients and patient advocates are represented.

RECRUITMENT AND RETENTIONA key tenet of PCORnet is engaging patients in all steps of the research process, from the development and prioritization of research questions, through data collection, dissemination and publication, to integration of results into healthcare practices. Engaging patients with rare diseases in each of these activities involves unique challenges and opportunities; however the Rare Disease Task Force (RDTF) members have found that addressing challenges and highlighting opportunities related to recruitment and retention are of particular importance. As such, this guidance document provides an overview of potential strategies for increasing patient recruitment and retention.

Recruitment and retention of rare disease research cohorts is challenging because of several key factors. Each rare disease affects a small percentage of the population; in the United States, a rare disease is defined as one in which fewer than 200,000 Americans are affected.1 Identifying members of rare disease populations is difficult because of broad, national and international geographic distribution of patients. Together, these two factors contribute to the overall challenge of very small sample size.

Small sample size also impacts other areas related to recruitment and retention. For example, the relatively small sample size introduces the need for a larger percentage of patients to achieve a representative sample for many research studies. Large percentages of rare disease cohorts are difficult to achieve when multiple studies compete for similar patients. Small sample size also introduces a need for heightened measures to provide security and protection of participant anonymity because identity cannot be ‘lost in the numbers’.

In addition to recruitment challenges, retention of participants in rare disease research in part because rare disease research studies often extend over long periods of time and require a wide spectrum of healthcare encounters. Participants with aggressive forms of a rare disease often have limited ability to participate in studies with long duration. Other factors that impact retention of participants in rare disease research include: The heightened need for transparent communication, the need to establish trust and a culture that demonstrates how the preferences and priorities of patients and families are valued by the research team.

Despite the many challenges associated with recruiting and retaining rare disease patients in research, many opportunities exist. For example, individuals with rare diseases (or their parents, family members, or caregivers) are often highly motivated to participate in research because understanding the disease and treatment options is critical for managing the illness, increasing quality of life and extending lifespan. Members of the RDTF noted anecdotally, that rare disease communities sometimes feel neglected by researchers and are urgent for better disease understanding and new interventions. After they capture the attention of researchers, however, such families can be at risk for research fatigue.


Fatigue can result from frequent requests to participate in research, the burden associated with participating in multiple studies, and the lack of follow up or information reported back to the patient about how his/her participation can help him/her or someone else in their disease community. Heavily researched communities may develop preferences for participating in particular types of research (e.g., comparative effectiveness over quality-of-life studies) or communities may develop an aversion to certain research approaches (e.g., unwillingness to participate in clinical trials using a placebo-controlled design). The availability of multiple clinical research opportunities often leads to difficult decisions for patients and families, who may have to choose among potentially beneficial options using uncertain or incomplete information.

LAYING THE GROUNDWORK

It is important to identify strategies to address the challenges, to share lessons learned from experiences and to provide anecdotal references for understanding the complexities of recruitment and retention in the rare disease population. Although many of these approaches are relevant to both common and rare conditions, all the ideas suggested by RDTF members have been included below so that this compilation might serve as an in-depth resource for recruitment and retention of trial participants from rare disease cohorts.

As an organizing framework for these strategies, we adapted a conceptual model from Ford et al.2 that describes three components that may promote participation in a clinical trial:

1. Awareness of clinical trials. This may include outreach and collaboration with rare disease organizations to engage patients, offering information about the rare condition, discussing trial/study possibilities, and presenting workshops or focus groups.

2. Opportunity to participate. This may include helping to address potential costs or burdens of participation such as transportation concerns, time commitments, or other logistical issues.

3. Decision-making. This may involve promoting a willingness to participate by conveying benefits or offering incentives (financial or nonfinancial).

Many of the approaches and strategies described here will be useful in all phases of engaging participants—from laying the groundwork through recruitment and retention.

The following approaches may be helpful in laying the groundwork.

Awareness

Be transparent and honest : Describe what is known and unknown about the potential risks and benefits of the research. Because patients and families are often desperate for treatment advances related to their disease, managing expectations is critical.


Engage with all organizations : When there are multiple groups serving a given rare disease, try to develop an impartial work relationship to gain acceptance from the patient community as a whole.

Plan ahead : Give organizations time to prepare their members to receive information about potential research in the planning stages.

Be visible: Attend and speak at patient/disease advocacy organization conferences early in research planning so their constituents can begin to know the investigators and research team and provide the patient perspective early enough in the process. This helps to build trust and loyalty for the team’s work in general as well as the in the current study.

Leverage existing relationships : Realize that when researchers have direct contact with the organizations, organization leaders are better able to talk with their constituents about the study. This lends credibility to the organization’s work, which in turn increases support for the organization.

Cast a wide net: When there is no organization serving a particular rare disease, contact “umbrella” groups that have platforms for many conditions or cross-conditions. There are several such groups, including the Genetic Alliance3 and the National Organization for Rare Disorders (NORD).4

Opportunity Consider the patient’s perspective : Develop or refine the research question to meet a true need

of the community. Patient-friendly approach : Use methods that are acceptable to the patient community. Minimize the patient investment : Consider the study design and proposed workflow from the

perspective of study participants; seek opportunities to reduce the time and resource participants and their families must invest.

Think outside of the box : Understand alternative paths for recruitment and dissemination of information.

Decision-making

Transparent motives : Help patients and family members know why you are interested in this condition. Describe your work and show them why their help and participation are essential. Patients appreciate knowing the project’s final goal, so discussing short-term, intermediate, and long-term goals is critical. For example, a natural history study is considered an immediate short-term goal, which then leads to the long-term goal of a new therapy.

Community engagement : Invite patients or patient representatives to be members or advisors of the research team.

Show the impact : Utilize patient and community input to make decisions and be transparent about where and how their input was impactful.


RECRUITMENT

There is a limited patient pool for recruitment in rare disease communities, which amplifies the need for customized recruitment activities. To develop focused strategies, it is important that researchers understand the sentiments of the affected community, including their thoughts, attitudes, and beliefs about research and their personal interactions with both healthcare and clinical research. Authentic engagement involves both parties listening intently for mutual benefit, rather than reaching a predefined end result.

In the high-stakes recruitment for clinical trials, sponsors need to be aware of competing research opportunities and must adhere to the highest ethical and moral standards in recruitment. Condition-specific foundations may be able to inform sponsors of competing research and suggest approaches to engaging the community effectively and fairly.

Additionally, identifying potential participants for rare disease research can be challenging because of widespread geographic distribution or lack of precise ICD codes or other signals in electronic health data. Identification of new participants may require significant time and effort per individual case and can often cost more per case than a research program for a common disease. Prospective researchers should anticipate and budget for costs related to identifying individuals affected by rare diseases. In many cases a confirmation (often molecular) of diagnosis is needed; it is recommended that this step be built into the recruitment phase.

While there is no generic, standard approach for recruitment in rare diseases, the specific condition might make some outreach approaches more feasible than others. For example, for rare conditions with fewer than 100 patients, personal emails or phone calls might be feasible but likely would not be for rare conditions affecting thousands of individuals. Often, rare disease networks are available on the internet or social media that can help in identification and recruitment, but integrating messages about recruitment into social support sites can be a challenge.

Successful strategies for identifying and recruiting patients involve engaging patients and patient support organizations; two-way communication and seeking input early; respecting the patient’s limited time and resources for research; and empowering patients with information and opportunities for networking, learning, and action. When individuals are managing debilitating diseases that require considerable time and effort, be mindful to impose as little additional burden to participation as possible. The following approaches have proven useful for recruiting participants in rare disease research initiatives and will be updated periodically by RDTF members as they complete their PCORnet research activities.

Awareness

Step Out : Engage with the rare disease communities where they already convene (e.g., meetings, organizations, clinics, and community groups).


Focus in: Conduct focus groups or other outreach with multidisciplinary stakeholders to identify unique or particularly effective recruitment strategies. (See PCORnet investigators from Vanderbilt for examples of the Patient Engagement Studies for one model.5)

Ask questions : Engage with communities to ask (and convey your intent to answer) questions that are important to the disease community.

Send the right message : Work with organizations to develop the recruitment message. When possible, customize materials to address pervasive concerns or overcome ambivalent or negative attitudes toward research, while taking care not to overstate potential benefits or create coercive communications.

Leverage technology: Use social media to announce study options. This may be most effective and acceptable to regulatory bodies when done in collaboration with a disease-focused foundation.

Leverage existing forums : Take advantage of rare disease community resources; for example, host webinars or other meetings through foundation networks or attend conferences and events sponsored by the community.

Opportunity

Plan for the future : Analyze comments and suggestions provided by patients and families for themes for future research of specific interest to the disease community.

Consider the usability factor : Develop protocols and materials that are sensitive to patients’ and family members’ perspectives.

Be realistic : Involve patients and caregivers in the clinical study design to ensure that inclusion and exclusion criteria, number of study visits, and study procedures are both acceptable and reasonable for participants.

Write for the readers: Explore meaningful, but minimally burdensome, consent processes that take into account disease-imposed limitations, if relevant. There is a critical balance between making consent simple and understandable while keeping patients fully informed of the risks of research. We encourage -PCORnet members to share new platforms, strategies, and examples in this area.

‘Need to know’ vs ‘Nice to know’: Ensure that informed consent documents are complete with regard to key points that could affect the patient. To the extent allowed by your IRB, avoid the use of inconsequential notices and warnings that detract from the reader’s ability to distinguish between real and theoretical risks and between risks of high and low likelihood or impact. PCORnet members are encouraged to share example consents on the PCORnet Central Desktop to help others in this area.

Integrate research and care delivery : Integrate recruitment activities into the support and clinical care flow for patients when possible.

Use a multifaceted approach : Collect information needed to connect with patients (or their families) by several methods (phone, text, email, etc.) to reduce the chance that they will be lost to follow-up.


Engage locally : When blood draws are needed, make arrangements for participants to have them drawn locally. Cover costs of sampling and provide prepackaged/labeled containers with all necessary information and instructions.

Empower the local experts : Identify clinicians who see patients with the condition and enlist their support. Familiarizing them with your research lets them have meaningful discussions when a patient brings up the proposed study in a medical visit.

Home court advantage : When research participants are children or adults unable to travel alone, it may be difficult for a parent or caregiver to take time off work to go to a research location, even if they are motivated. Efforts to minimize travel requirements and distance are appreciated. Examples include partnerships with local clinicians or researchers to ease travel burden.

Leverage available resources : When travel to the research location is unavoidable and study funds are not provided, help participants connect with other resources to expedite travel (e.g., Miracle Flight). Or, for families of children, provide low-cost or no-cost accommodations (e.g., Children’s Inn, Ronald McDonald House). Meal vouchers and information about local patient organizations and connections to medical social work teams can be helpful and are often appreciated.

Go where the people are : Leverage existing meeting opportunities and resources. For example, integrate with other groups who serve the affected individuals; engage in established meetings such as Individualized Education Plan (IEP) discussions or with established online resources such as web-based disability resources, etc. Leaders of organizations can assist with this.

Go paperless : Keep paperwork to a minimum and send it to potential participants in advance. Move toward paperless and consider getting information via interview rather than in writing, or give participants a choice in mode of information collection.

Connect the dots: When connections are made with people who are not affiliated with an organization, offer information about relevant organizations. If patients have trouble making contact, offer to facilitate.

Knowledge is power : Offer incentives, if possible. The rare disease community is often incentivized by knowledge more than by money. If a monetary incentive is offered, give them the option of having it in the form of a donation to the organization.

Decision-making

Explain the rationale : Include in the information flow a message that informs patients what the research can mean to them. Even if the knowledge gained through research is general, people affected by the condition want to know the research will enable providers to make informed treatment decisions and plan future research. Researchers can help patients and families understand that although research is not the same as clinical treatment, it is beneficial and important to them and to their future.

Create a value statement : Communicate the benefits of research participation to the community and to the individual participant (e.g., in the form of access to information, expertise, and support).


Build trust: Ensure that the data will be collected, maintained, and distributed by a trusted source. In the registry context, this should be a community source that aims to speed disease-specific research. Communicate this message to research sponsors and partners, including patients and disease advocacy groups. Research participants and their families want to know that their data will be used to support future research, and knowing that a research team is committed to sharing data and results can enhance participation.

Report back: Provide feedback to disease community resources, such as how many people have participated in the research so far and how many more you need, or when scientific results will be presented (e.g., at meetings). Organizations can relay this information so that individuals receive it from several sources.

You’re invited: Host patient-focused meetings or reunions and incorporate research discussions at those times.

Peer to peer communication : Ask participants to help spread the word to other potential participants.

Teach the man to fish: Provide participants with vetted resources (e.g., educational materials, online tools) for assistance with issues they may encounter as part of their condition.

Facilitate connections : If an organization does not currently exist to serve people with the condition, join with a patient or family to organize support group meetings at your location or find a way for participants who are geographically distant to connect with each other. Help them build a community that you can re-connect with in the future.

Remember that the quality of interaction you have with people involved in the study, and their families and caregivers as appropriate, is important. They need to know they are not alone, that they are doing a great job, are valued, and have unique talents. Give lots of positive reinforcement.

RETENTION

Given the low number of people with rare conditions and the difficulty recruiting, it is critical that participants remain in the study or registry and continue to answer questions and update information. However, such patients are often coping with serious disorders, or dealing with a healthcare system that is unequipped or uninformed about how to provide them with care, or needing social services and supports that are typically difficult to access or maintain.

Patients with rare diseases are often strong advocates for research, yet they must perceive some benefit—or only limited burden—to remain engaged in the process. RDTF members have identified the following successful strategies for retaining participants in research.

Awareness

Impact the future : Empower study participants; emphasize how they are making a difference not only in their own lives but also in every patient diagnosed after them.

Be an ambassador : Motivate participants to understand and address unanswered questions in the community.


Engage the support systems: Conduct outreach to “navigators”—people who help patients traverse the condition from point of diagnosis until they are independently managing life with the condition.

Leverage technology : Use social media to provide updates on studies (e.g., recruitment efforts, preliminary results, upcoming activities).

Foster connections : Host events for participants and researchers to gather and meet one another.

Capture the moment: Take photos and post on social media (with photo permissions in advance).

Learn from the experts : Invite leaders of organizations to your events and ask them to speak. Share results : During study design and start-up, researchers and stakeholders can

collaboratively develop a dissemination plan for real-time updates to study participants and stakeholders. Share results of final analyses at advocacy conferences, via webinars, or by creating a brief description for social media, newsletters, etc. Note: Brief lay summaries often can be shared without having an adverse impact on the researcher’s ability to publish.

Opportunity

Patients can decide: Consider forms of dynamic and granular engagement that allow the participant to make choices about what information they will share, how they will share it, and with whom it can be shared.

Leverage technology: Reduce the burden of updating information by using relevant technologies.

Give a gift Tie requests for new or updated information with a “give back” to the participant such as an educational or support tool.

Stay local: Minimize the number of visits requiring travel to clinic. Engage patients in prototype development : Develop user-friendly web-portals and pilot-test

them with participants. Compensate for travel : Provide financial support or other forms of assistance to facilitate travel

to study sites when required. Celebrate: Send birthday and holiday cards from the study team as a way to show your

continued interest and to keep up-to-date contact information.

Decision-making

Provide context : Allow participants to view their own score for an assessment in the context of an aggregate score for measures submitted by all comparable participants. Alternatively, provide participants with some framework in which they can interpret their responses to individual items on a questionnaire in the context of the responses submitted by the greater participant community.

Build on prior work : Explore opportunities to repurpose registry data in clinical tools for patients or health care providers; similarly, explore opportunities to leverage data that is available from patients and health care providers for use in research.


Expand authorship : Name the organization and their leaders as coauthors of your research. This approach enhances collaboration and allows them a larger stake in the research as well as helping with patient retention and follow-up.

Lessons learned: Ask research participants what they would do differently if they were the researcher.

Share resources : If the research team finds a new resource, send it to the organization or directly to the patients in the study.

Spread the word: Formally publish research results and share the manuscripts with study participants.

Describe the use: Document and report the number of researchers who cite these publications to facilitate connections across research initiatives.

In summary, the PCORnet RDTF offers a collection of recommendations to support the recruitment and retention of patients in rare disease research. Themes including empowerment, education, and transparency emerge as essential components of an effective plan to recruit and retain qualified participants in efforts that advance knowledge and science needed to improve the health and quality of life for patients, families and caregivers whose lives are affected by rare conditions.

REFERENCE LIST

1. U.S. Food and Drug Administration. Available at: http://www.fda.gov/RegulatoryInformation/Legislation/FederalFoodDrugandCosmeticActFDCAct/SignificantAmendmentstotheFDCAct/OrphanDrugAct/default.htm. Accessed November 10, 2014.

2. Ford JG, Howerton MW, Bolen S, et al. Knowledge and access to information on recruitment of underrepresented populations to cancer clinical trials. Evid Rep Technol Assess (Summ) 2005(122):1-11. PMID:15989377.

3. Genetic Alliance. http://www.geneticalliance.org/.

4. National Organization for Rare Diseases. https://www.rarediseases.org/.

5. Wilkins CH, Joosten Y. Improving Patient Engagement and Understanding Its Impact on Research. NIH Collaboratory Grand Rounds Presentation. August 2014. Available at: https://www.nihcollaboratory.org/Pages/Grand-Rounds-08-29-14.aspx. Accessed November 10, 2014.


RESOURCESA number of general resources exist to support the recruitment and retention of participants in clinical research. This list is not exhaustive or limited to rare diseases but should be helpful to inform general approaches and guidance.

Resource Name Location

1 Brescia BA. 2013. Two Sides of the Rare Disease Coin and Three Insights Into Patient Retention

http://innovations.bbkworldwide.com/bid/176555/Two-Sides-of-the-Rare-Disease-Coin-and-Three-Insights-Into-Patient-Retention#gsc.tab=0

2 Chapter 20: Rare Disease Registries. In Registries for Evaluation of Patient Outcomes, 3rd Edition: A User’s Guide

http://www.ncbi.nlm.nih.gov/books/NBK208609/

3 DeWard SJ, et al. 2014. Practical Aspects of Recruitment and Retention in Clinical Trials of Rare Genetic Diseases: The Phenylketonuria (PKU) Experience

http://www.ncbi.nlm.nih.gov/pubmed/24014152

4 Forsythe LP, et al. 2014. A Systematic Review of Approaches for Engaging Patients for Research on Rare Diseases


5 Gupta S, et al. 2011. Rare Lung Disease Research: Strategies for Improving Identification and Recruitment of Research Participants


6 Kaye J, et al. 2012. From Patients to Partners: Participant-Centric Initiatives in Biomedical Research. Nature Reviews Genetics, 13, 371-376.

http://www.nature.com/nrg/journal/v13/n5/abs/nrg3218.html

7 Kaye J, et al. 2014. Dynamic Consent: A Patient Interface for Twenty-First Century Research Networks. Eur J Hum Genet.


8 Orphan Reach: Patient Retention http://orphan-reach.com/rare-disease-focus/optimize-patient-retention

9 Participant Engagement: Tools to Meet People Where They Are (NIH Collaboratory Grand Rounds Presentation by Sharon Terry)

https://www.nihcollaboratory.org/Pages/Grand-Rounds-02-21-14.aspx




http://orphan-reach.com/rare-disease-focus/optimize-patient-retention

http://orphan-reach.com/rare-disease-focus/optimize-patient-retention
















Resource Name Location

10 Partnering With and Engaging Families in Clinical Research (NIH Collaboratory Grand Rounds Presentation by Megan O’Boyle)


11 Strange C, et al. 2014. Social Impact Identified In and By the Alpha-1 Antitrypsin Deficiency Community. Rare Diseases and Orphan Drugs

http://rarejournal.org/rarejournal/article/view/59

12 Terry SF, et al. 2013 The Haystack is Made of Needles. Genet Test Mol Biomarkers

http://www.ncbi.nlm.nih.gov/pubmed/?term=23428177

13 The Use of Social Media in Clinical Research (NIH Collaboratory Grand Rounds Presentation by Stephanie Startz)


14 WikiAdvocacy, Functions of Advocacy Organization

http://wikiadvocacy.org/index.php/Functions_of_Advocacy_Organization#Support












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