In the RESOLVE trial of remote cognitive behavioral therapy for chronic pain, fewer than 3.5% of participants self-identified as Hispanic, well below that group's representation among people who actually live with chronic pain. The investigators pointed to English-only delivery and, more pointedly, lower comfort with digital platforms. That gap is not a rounding error. It captures a central tension in a new JAMA editorial examining what decentralized clinical trials are delivering.
The authors — Alison J. Huang, Gregory M. Marcus, and An-Wen Chan — open JAMA’s new JAMA+ Trials platform with a frank accounting of four recent remote trials. Together, those studies suggest that eliminating the physical research site does not automatically eliminate barriers to participation. It may simply trade one set of obstacles for another.
That reassessment comes as JAMA makes a broader case for why trials still matter. In a companion editorial launching JAMA+ Trials, editors describe randomized trials as the “bedrock of evidence-based medicine,” even when they produce inconvenient or practice-changing results. If trials remain the foundation of clinical decision-making, how they are conducted matters just as much as what they show.
Remote trial designs offer clear advantages. Wearables and smartphone apps can capture continuous physiological data in real-world conditions. Participation becomes more feasible for patients in rural areas, those with limited mobility, or those balancing work and caregiving demands. But these same models rely on reliable high-speed internet, compatible devices, and digital fluency to navigate study platforms — requirements that do not apply equally across age, education, or socioeconomic status.
“Rather than democratizing access to research, remote trials have the potential to create new or more problematic forms of trial exclusion.” — Huang, Marcus, and Chan, JAMA, April 15, 2026
What emerges from the editorial’s analysis sits just beneath its measured tone: decentralized research has scaled quickly. But validation has not kept pace. Much of this infrastructure expanded during and after COVID-19, while key elements — including validation of remote outcome measures — remain incompletely validated. Many remotely collected endpoints, including proxies for physical examination findings, have not been formally tested against the in-person assessments they are meant to replace.
At the same time, participation burdens have not disappeared — they have shifted. Participants are now responsible for troubleshooting apps, managing devices, adapting their home environments, and sometimes collecting specimens without direct oversight.
The concern is whether remote trial populations may be becoming skewed — younger, more educated, and more digitally connected — in ways that limit generalizability. The RESOLVE trial’s Hispanic underrepresentation, the AMALFI trial’s 15% non-use rate for mailed ECG patches, and the PRACTICAL trial’s higher-than-expected non-initiation rates all point to the same structural issue: infrastructure optimized for convenience can quietly disadvantage the populations with the highest disease burden.
Not all findings point in the same direction. In the CASCADE trial, which used a hybrid model combining in-person recruitment with remote follow-up, roughly 40% of participants were from racial and ethnic minority groups — suggesting that design choices, not just technology, shape who ultimately participates.
Bottom line for clinicians: As remote trials become more common, the question is not just how convenient they are — but who they represent. Trialists and institutional review boards adopting remote-first designs may need to treat representativeness as a primary design constraint, not an afterthought. Hybrid models — offering both in-person and remote participation — may be particularly important in studies where digital access barriers are predictable, and the consequences of exclusion are high.
Disclosures for the authors of the referenced JAMA editorials are available in the original publications.
