Physician remuneration in industry-sponsored clinical trials: the case for standardized clinical trial budgets

Clinical trials bureaucracy: unintended consequences of well-intentioned policy

BackgroundAs randomized controlled trials have become the ‘gold standard’ for medical research, a complex regulatory structure for the conduct of clinical trials has emerged. However, this structure has not been adequately assessed to ensure that regulations governing human subjects research actually produce the desired effects.

PurposeOur purpose is to identify some of the major shortcomings in the current regulatory system of human clinical trials oversight, and to propose some potential solutions to these problems.

MethodsWe discuss the evolution of the current US regulatory environment and its application in the context of several widely-used drug therapies.

ResultsDespite numerous randomized controlled trials, performed within a structure of extensive documentation and data collection, serious shortcomings in a number of pharmaceutical therapies were not detected until after the drugs were approved and widely adopted by clinicians.

ConclusionThe current system of regulatory bureaucracy in clinical trials has led to an extremely expensive research paradigm that, in spite of complex systems of oversight and exhaustive data collection, cannot be shown to adequately ensure the integrity of the research process and the protection of human research subjects. Some parts of the system, including Research Ethics Review Boards, may not be well-suited to carrying out their core mission of overseeing research conduct, and other aspects of clinical trials regulatory structure, such as monitoring/auditing review and adverse event reporting, may constitute a waste of money and resources. Misdirected data collection and adverse events reporting divert valuable resources and hamper development of large, simple clinical trials powered to definitively answer important research questions. Careful scrutiny of the utility of current or proposed regulatory schemes is required to ensure the integrity of human subjects research and to enhance the effectiveness of research dollars.

Patient perspectives on physician conflict of interest in industry-sponsored clinical trials for multiple sclerosis therapeutics

BACKGROUND

Pharmaceutical industry financial support of physicians, physician practices, and academic departments involved in multicenter industry-sponsored clinical trials of novel therapeutic agents is a relatively new and infrequently acknowledged source of potential physician conflict of interest. Detailed disclosure of these relationships to study participants is not uniformly a part of informed consent and documentation practices.

OBJECTIVE

To understand attitudes of patients with multiple sclerosis concerning disclosure of potential physician-industry conflicts of interest created by clinical trials and how such disclosures may influence study participation

METHODS

An anonymous online instrument was developed.

RESULTS

597 people with multiple sclerosis participated in the study. The study found that detailed disclosure of conflicts of interest is important to potential participants in industry-sponsored clinical trials for multiple sclerosis therapies and that the presence of these conflicts of interest may influence patients' decisions to participate in these studies.

CONCLUSIONS

Findings from this study support a call for uniform guidelines regarding disclosure of physician-industry relationships to prospective research participants for industry-sponsored clinical trials.

Incremental costs of prostate cancer trials: Are clinical trials really a burden on a public payer system?

INTRODUCTION

Clinical trials are a critical component of improving cancer prevention and treatment strategies. However, the perception that patients enrolled in trials consume more resources than those receiving the standard-of-care (SOC) has contributed to an increasingly research-averse environment. Current economic data pertaining to the per-patient costs of prostate cancer trials relative to SOC treatment are limited.

METHODS

A retrospective observational cohort study was conducted to compare costs incurred by 59 prostate cancer patients participating in a mix of industry and non-industry sponsored clinical trials with costs incurred by an equal number of eligible non-participants who received SOC over a year. Resource utilization was tracked and quantified to standardized price templates.

RESULTS

No difference in overall resource utilization was seen between trial and SOC patients (two-tailed t-test, n = 118, p = 0.99). Variability in the types of resources used by each group indicated that, while trial patients may take up significantly more clinic time (p = 0.001) and undergo more tests and procedures (p = 0.001), SOC patients are more likely to receive other costly interventions, such as radiation therapy (p < 0.001). Other variables (e.g., pathology, diagnostic imaging, prescribed therapies) were statistically indistinguishable between groups.

CONCLUSION

This study revealed differences in the cost distribution of patients enrolled in clinical trials versus those receiving SOC, which could be used to improve resource allocation. The lack of evidence for a difference in overall cost provides an argument for payers to more fully support clinical research without fear of adverse financial consequences. Further analysis is required.

Better infrastructure: industry-academia partnerships--a marriage of convenience?

The successful design and completion of clinical trials often requires participation of both industry and academia. Although there may be differing priorities for academic and industry participants, both bring important insights and resources to the clinical trial effort. Although industry generally is primarily responsible for preclinical development and funding of the study and academia for patient recruitment and participation in the data safety monitoring board and clinical coordinating center, there are also a number of important areas, including protocol design, data analysis, and manuscript preparation where both academia and industry can supply important insights. Inherent tensions may exist in the academic-industry relationship, including important issues relating to conflict of interest for both academic and industry participants. Nevertheless, the academic-industry partnership, if appropriately organized, can perform in a synergistic fashion, allowing exploration of novel therapies, elucidation of important mechanisms, and greater understanding of critical illness through using combined approaches that generate insights unable to be provided by either partner alone.

National evaluation of policies on individual financial conflicts of interest in Canadian academic health science centers

BACKGROUND

Conflicts of interest (COI) in research are an important emerging topic of investigation and are frequently cited as a serious threat to the integrity of human participant research.

OBJECTIVE

To study financial conflicts of interest (FCOI) policies for individual investigators working in Canadian academic health centers.

DESIGN

Survey instrument containing 61 items related to FCOI.

SETTING

All Canadian academic health science centers (universities with faculties of medicine, faculties of medicine and teaching hospitals) were requested to provide their three primary FCOI policies.

MEASUREMENTS

Number of all centers and teaching hospitals with policies addressing each of the 61 items related to FCOI.

MAIN RESULTS

Only one item was addressed by all 74 centers. Thirteen items were present in fewer than 25% of centers. Fewer than one-quarter of hospitals required researchers to disclose FCOI to research participants. The role of research ethics boards (REBs) in hospitals was marginal.

LIMITATIONS

Asking centers to identify only three policies may not have inclusively identified all FCOI policies in use. Additionally, policies at other levels might apply. For instance, all institutions receiving federal grant money must comply with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans.

CONCLUSIONS

Canadian centers within the same level (for instance, teaching hospitals) differ significantly in the areas that their policies address and these policies differ widely in their coverage. Presently, no single policy in any Canadian center informs researchers about the broad range of individual FCOI issues. Canadian investigators need to understand the environment surrounding FCOI, be able to access and follow the relevant policies and be confident that they can avoid entering into a FCOI.

Guidelines on the ethics of clinical research in anaesthesia

PURPOSE OF REVIEW

This review will identify ethical issues arising from conflicts of interest in sponsored clinical trials, and the need for compliance with recent privacy legislation. It will guide investigators facing ethical dilemmas that compromise the integrity of their research because of conflicts of interest or a flawed consent process. Authors will learn about changes in journal editorial policies that will require registration of clinical trials and consent for publication of case reports.

RECENT FINDINGS

Recently, ethics review committees and clinical investigators have violated research ethical guidelines and authors have ignored journal policies on disclosure of data in multicentre clinical trials. Published reports show selective reporting of data from clinical trials that biases the body of evidence available for clinical decision-making. Privacy laws legislate that patient consent for the use of their health information, other than for their clinical care, must be obtained explicitly.

SUMMARY

Clinical trial registration and the need for consent for publication of case reports aim to restore and improve the integrity of biomedical publication. Journal policies that incorporate these changes may be persuasive in interpreting privacy laws, in a practical way, to protect patients from harm. It is difficult to eliminate all ethical problems with sponsored trials and government regulatory drug-approval processes may require review.