Private manufacturers' thresholds to invest in comparative effectiveness trials

Ethics of Informed Consent for Pragmatic Trials with New Interventions

OBJECTIVES

Pragmatic trials evaluate the comparative benefits, risks, and burdens of health care interventions in real-world conditions. Such studies are now recognized as valuable to the perimarketing stage of drug development and evaluation, with early pragmatic trials (EPTs) being explored as a means to generate real-world evidence at the time of regulatory market approval. In this article, we present an analysis of the ethical issues involved in informed consent for EPTs, in light of the generally recognized concern that traditional ethical rules governing randomized clinical trials, such as lengthy informed consent procedures, could threaten the "real world" nature of such trials. Specifically, we examine to what extent modifications (waivers or alterations) to regulatory consent for EPTs would be ethical.

METHODS

We first identify broadly accepted necessary conditions for modifications of informed consent (namely, the research involves no more than minimal risk of harm, the research is impracticable with regulatory consent, and the alternative to regulatory consent does not violate legitimate patient expectations) and then apply those criteria to the premarket and early postmarket contexts.

RESULTS AND CONCLUSIONS

The analysis shows that neither waivers nor alterations of regulatory consent for premarket EPTs will be ethically permissible. For postmarket EPTs with newly approved interventions, waivers of consent will be ethically problematic, but some studies might be conducted in an ethical manner with alterations to regulatory consent.

Burden of illness and research investments in translational sciences for pharmaceuticals in metastatic cancers

AIM

To explore whether investments in translational sciences for six metastatic cancers follow idiosyncratic returns to those investments rather than levels of burden of illness (BI).

METHODS

Associate the number of translational clinical trials in the USA involving oncolytic drugs approved during 2008-2013 and the level (in 2008) and changes (2002-2008 and 2008-2014) in cancer-specific years of life lost.

RESULTS

Investments in trials were positively associated only with contemporary changes in BI (2008-2014). The relationship was stronger for government-sponsored comparative-effectiveness trials than for industry.

CONCLUSION

Translational research investments follow anticipated changes to BI levels. Systematic quantification of these expected returns from specific investments can help guide investment decisions in translational health sciences and generate productive dialogue across stakeholders.

Futurescapes: evidence expectations in the USA for comparative effectiveness research for drugs in 2020

AIM

Explore key factors influencing future expectations for the production of evidence from comparative effectiveness research for drugs in the USA in 2020 and construct three plausible future scenarios.

MATERIALS & METHODS

Semistructured key informant interviews and three rounds of modified Delphi with systematic scenario-building methods.

RESULTS & CONCLUSION

Most influential key factors were: health delivery system integration; electronic health record development; exploitation of very large databases and mixed data sources; and proactive patient engagement in research. The scenario deemed most likely entailed uneven development of large integrated health systems with pockets of increased provider risk for patient care, enhanced data collection systems, changing incentives to do comparative effectiveness research and new opportunities for evidence generation partnerships.