Maintaining integrity and credibility in industry-sponsored clinical research

How research ethics boards should monitor clinical research

The objective of this commentary is to provide a framework and ethical justification for a more proactive model of continual, active monitoring of research. We outline what the increased monitoring should consist of, and the practical constraints associated with executing these monitoring functions. We also defend the idea that adequate post-initial-review monitoring requires greater REB involvement, rather than trust and researcher's assurances.

Scientific integrity: critical issues in environmental health research

Environmental health research is a relatively new scientific area with much interdisciplinary collaboration. Regardless of which human population is included in field studies (e.g., general population, working population, children, elderly, vulnerable sub-groups, etc.) their conduct must guarantee well acknowledged ethical principles. These principles, along with codes of conduct, are aimed at protecting study participants from research-related undesired effects and guarantee research integrity. A central role is attributed to the need for informing potential participants (i.e., recruited subjects who may be enrolled in a study), obtaining their written informed consent to participate, and making them aware of their right to refuse to participate at any time and for any reason. Data protection is also required and communication of study findings must respect participant's willingness to know or not know. This is specifically relevant for studies including biological markers and/or storing biological samples that might be analysed years later to tackle research objectives that were specified and communicated to participants at the time of recruitment or that may be formulated after consent was obtained.Integrity is central to environmental health research searching for causal relations. It requires open communication and trust and any violation (i.e., research misconduct, including fabrication or falsification of data, plagiarism, conflicting interests, etc.) may endanger the societal trust in the research community as well as jeopardize participation rates in field projects.

Conducting industry-partnered trials in orthopaedic surgery

We have seen an emergence of larger scale collaborative multi-center trials in surgery. These larger trials have the advantage of increased generalisability of the results and the potential for large scale and efficient recruitment (1000 patients or more). It is estimated that the average cost of bringing a new drug to market approximates 500 million dollars. The funding limitations in most national peer-reviewed agencies provides a compelling rationale for industry co-sponsors. To limit biases associated with industry-sponsored research, researchers should develop specific protocols to ensure accurate and transparent reporting of funding sources, design and implementation of surgical trials, manuscript preparation and the criteria for authorship.

Conflict of interest in industry-sponsored economic evaluations: real or imagined?

As industry sponsorship of pharmacoeconomic studies has increased, concerns have been raised about potential biases, owing to the conflicts of interest that this sponsorship creates. A review of the literature indicates that there are some causes for concern, given the fact that most pharmacoeconomic studies report positive findings for the sponsor's drug. However, a more detailed analysis suggests that, although the methodologic quality of some published studies may be poor, the main reason for positive results is that companies only sponsor economic studies where a positive outcome is likely. Therefore, it is concluded that the best way of dealing with perceptions of sponsorship bias is not increased rhetoric, but rather increased public funding for economic evaluation of medicines, thereby creating a true mixed economy for research funding in this field.

The role of biostatistics in the prevention, detection and treatment of fraud in clinical trials

Recent cases of fraud in clinical trials have attracted considerable media attention, but relatively little reaction from the biostatistical community. In this paper we argue that biostatisticians should be involved in preventing fraud (as well as unintentional errors), detecting it, and quantifying its impact on the outcome of clinical trials. We use the term 'fraud' specifically to refer to data fabrication (making up data values) and falsification (changing data values). Reported cases of such fraud involve cheating on inclusion criteria so that ineligible patients can enter the trial, and fabricating data so that no requested data are missing. Such types of fraud are partially preventable through a simplification of the eligibility criteria and through a reduction in the amount of data requested. These two measures are feasible and desirable in a surprisingly large number of clinical trials, and neither of them in any way jeopardizes the validity of the trial results. With regards to detection of fraud, a brute force approach has traditionally been used, whereby the participating centres undergo extensive monitoring involving up to 100 per cent verification of their case records. The cost-effectiveness of this approach seems highly debatable, since one could implement quality control through random sampling schemes, as is done in fields other than clinical medicine. Moreover, there are statistical techniques available (but insufficiently used) to detect 'strange' patterns in the data including, but no limited to, techniques for studying outliers, inliers, overdispersion, underdispersion and correlations or lack thereof. These techniques all rest upon the premise that it is quite difficult to invent plausible data, particularly highly dimensional multivariate data. The multicentric nature of clinical trials also offers an opportunity to check the plausibility of the data submitted by one centre by comparing them with the data from all other centres. Finally, with fraud detected, it is essential to quantify its likely impact upon the outcome of the clinical trial. Many instances of fraud in clinical trials, although morally reprehensible, have a negligible impact on the trial's scientific conclusions.

Recent trends and controversies in industry-sponsored clinical trials

In recent years, industry has become an important source of funding for biomedical research. Industry-sponsored clinical trials are a particular source of controversy. In light of recent developments, the authors reevaluate the 1995 SAEM guidelines for investigator involvement in industry-sponsored clinical trials. The authors divide industry-funded clinical trials into two categories: investigator-initiated and industry-initiated, and discuss the differences between them. They examine several areas of ethical debate, including exclusivity contracts between a principal investigator and a corporate sponsor, the size of per-patient reimbursements for recruiting patients into clinical trials, and authorship criteria. Finally, the authors oppose the assumption that industry-sponsored research is automatically biased, and suggest that multiple levels of review will help to uncover bias, whatever the source. Once mutual respect for ethical guidelines and practices are established, collaboration between emergency medicine researchers and industry should be encouraged.

Conflicts of interest in emergency medicine

Conflicts of interest have become prevalent in the daily practice of emergency medicine because physician relationships with patients, hospitals, insurers, and the medical industry have become increasingly complex. Conflict resolution requires both physician recognition and available resources to avoid engaging in a conflict that may jeopardize public confidence regarding patient advocacy. This article analyzes the essential characteristics of several conflicts of interest that apply to emergency physicians, and reviews rational ways to systematically avoid or curtail them.

Infections in intraabdominal surgery. The EURESI Project. European Research Network on Surgical Infections

The situation of clinical research in Europe must be improved substantially according to statements of scientists, managers and politicians. The analysis of requirements is available; however, there are no indications that the conclusion of the analysis is being converted into actual facts. Government programs, although originally conceived to improve the situation of clinical research, are used to maintain the status quo. The European Research Network on Surgical Infections (EURESI) concept has been developed by scientists and clinicians from European institutions and university hospitals to make the first steps possible in a new cooperation in European research. With regard to the essentials for clinical research, formulated according to a survey among research-oriented pharmaceutical companies, EURESI was successful in the following objectives: 1) competence in clinical research, 2) capacity for clinical studies, 3) internal quality control, 4) special know-how relevant to clinical studies, 5) performance according to a time plan, 6) interdisciplinianism, 7) contract partnership, 8) organization of research meetings. This special addendum includes presentations at the EURESI meeting in Heidelberg/Weinheim with special reference to the requirements for clinical studies in intraabdominal infections to further stimulate contact with the network.

Influences on the quality of published drug studies

To practice evidence-based medicine, physicians need data on the clinical effectiveness, toxicity, convenience, and cost of new drugs compared with available alternatives. We give examples of published drug studies that are defective, sometimes because pharmaceutical industry funding has affected their content and quality. We make recommendations on how to avoid these defects.

Monitoring of clinical trials: issues and recommendations

Interim analyses of randomized trials enable investigators to make more efficient use of limited research resources and to satisfy ethical requirements that a regimen be discontinued as soon as it has been established to have an inferior efficacy/toxicity profile. Unfortunately, the integrity and credibility of these trials can be compromised if inappropriate procedures are used in monitoring interim data. In this paper we discuss how group sequential designs provide useful guidelines that enable one to satisfy the valid objectives of interim monitoring while avoiding undesirable consequences, and we consider how flexible one can be in the way such designs are implemented. We also provide motivation for the role of data-monitoring committees in preserving study integrity and credibility in either government- or industry-sponsored trials. In our view, these committees should have multidisciplinary representation and membership limited to individuals free of apparent significant conflict of interest, and ideally should be the only individuals to whom the data analysis center provides interim results on relative efficacy of treatment regimens. Finally, we discuss some important practical issues such as estimation following group sequential testing, analysis of secondary outcomes after using a group sequential design applied to a primary outcome, early stopping of negative trials, and the role of administrative analyses.