Trial registers: protecting patients, advancing trust

Characteristics of studies of pharmacist services registered in ClinicalTrials.gov

OBJECTIVE

To examine the characteristics of studies of pharmacist services registered in ClinicalTrials.gov.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

ClinicalTrials.gov and MEDLINE databases were searched to identify studies of pharmacist services. Registration information was obtained from the Aggregate Analysis of ClinicalTrials.gov (AACT) database. Studies were excluded if the ClinicalTrials.gov submission date was after December 31, 2018; there were no U.S. study sites; pharmacist services were not mentioned; or pharmacist involvement was limited to medication dispensing, randomization, or measuring study outcomes.

OUTCOME MEASURES

Characteristics of registered studies from ClinicalTrials.gov and AACT data, categories of pharmacist services, changes in registration and focus of pharmacist services over time, and relationships between funding source and result availability and between the focus of pharmacist services and types of outcomes and types of pharmacist interventions.

RESULTS

Overall 401 studies were identified for initial review, with 151 included for detailed review. Pharmacist services were the only intervention in 68 studies (45.0%), a separate intervention in 14 (9.3%), and part of a combined intervention in 40 (26.5%). In 29 studies (19.2%), pharmacist services were not the focus. Registered studies primarily were interventional, randomized, and open-label; included behavioral or "other" interventions; were conducted in the outpatient setting; and were sponsored by "other" sources. The most common health conditions were hypertension and diabetes. Only 29 of the 104 completed studies (27.9%) posted results. Clinical outcomes were the most common primary (80; 53.0%) and secondary outcomes (66; 58.9%). Medication management (69; 45.7%) and patient education or counseling (88; 58.3%) were the most common types of pharmacist interventions.

CONCLUSION

This analysis of ClinicalTrials.gov identified 151 studies of pharmacist services in the United States registered through the end of 2018. Given the breadth of the pharmacy services literature, there is room for improvement in the registration of these types of studies.

Threats to reliability risk erroneous conclusions: a survey of prospective registration and sample sizes of randomised trials in women's health

OBJECTIVE

Prospective registration of clinical trials has been required since 2005. We aimed to assess concordance between registered and reported sample sizes among prospectively registered randomised controlled trials (RCTs) in obstetrics and gynaecology.

DESIGN

Analysis of prospectively registered and published data.

SETTING

Women's health.

SAMPLE

Obstetrics and gynaecology RCTs published in eight journals in 2015.

METHODS

Specialist (Acta Obstet Gynecol Scand, BJOG, Obstet Gynecol and Am J Obstet Gynecol) and general (BMJ, N Engl J Med, JAMA and Lancet) journals were searched from 1 January to 31 December 2015 for main reports of obstetrics and gynaecology RCTs. Their corresponding registries and protocols were sought and data were extracted. Proportions and 95% CI were calculated using exact methods.

MAIN OUTCOME MEASURES

Prospective registration of RCT and sample size concordance between RCTs and their registries within those where registration took place before patients were recruited.

RESULTS

Of the 75 relevant RCTs, 51 (68%, 95% CI 56-78%, P < 0.001 using a null hypothesis requiring 100% compliance) were prospectively registered, a feature found to be more common in general journals versus specialist journals (21/22 versus 30/53, 95% versus 57%, P = 0.001). Of the 51 prospectively registered RCTs, 31 (61%, 95% CI 46-74%, P = 0.003 using a null hypothesis requiring 40% of studies to achieve their stated sample size) did not reach the target sample size.

CONCLUSIONS

There are gaps in universal adoption of the prospective trial registration rule. Inability to meet target sample size risks deficiencies in statistical power with unreliability in results.

TWEETABLE ABSTRACT

Only two-thirds of RCTs in women's health are prospectively registered, and over half fail to achieve target sample sizes.

Dry eye disease treatment: a systematic review of published trials and a critical appraisal of therapeutic strategies

Dry eye disease (DED) treatment is an area of increasing complexity, with the emergence of several new treatment agents in recent years. Evaluation of the efficacy of these agents is limited by heterogeneity in outcomes definition and the small number of comparative studies. We provide a systematic review of clinical trials (CTs) related to DED treatment and a critical appraisal of CT public databases. CT reports obtained from eight databases were reviewed, as well as public free-access electronic databases for CT registration. Data evaluation was based on endpoints such as symptoms, Schirmer test, ocular surface staining scores, recruitment of patients, type and efficacy of the drug, and the design and site of performance of the study. Forty-nine CTs were evaluated involving 5,189 patients receiving DED treatment. Heterogeneity in study design prevented meta-analysis from yielding meaningful results, and a descriptive analysis of these studies was conducted. The most frequent categories of drugs for DED in these studies were artificial tears, followed by anti-inflammatory drugs and secretagogues. Although 116 studies have been completed, according to the registration database for clinical trials, only 17 of them (15.5%) were published. Out of 185 registered CTs related to DED, 72% were performed in the USA. The pharmaceutical industry sponsored 78% of them. The identification of effective DED treatment strategies is hindered by the lack of an accepted set of definitive criteria for evaluating disease severity.

Guidance in social and ethical issues related to clinical, diagnostic care and novel therapies for hereditary neuromuscular rare diseases: "translating" the translational

Drug trials in children engage with many ethical issues, from drug-related safety concerns to communication with patients and parents, and recruitment and informed consent procedures. This paper addresses the field of neuromuscular disorders where the possibility of genetic, mutation-specific treatments, has added new complexity. Not only must trial design address issues of equity of access, but researchers must also think through the implications of adopting a personalised medicine approach, which requires a precise molecular diagnosis, in addition to other implications of developing orphan drugs. It is against this background of change and complexity that the Project Ethics Council (PEC) was established within the TREAT-NMD EU Network of Excellence. The PEC is a high level advisory group that draws upon the expertise of its interdisciplinary membership which includes clinicians, lawyers, scientists, parents, representatives of patient organisations, social scientists and ethicists. In this paper we describe the establishment and terms of reference of the PEC, give an indication of the range and depth of its work and provide some analysis of the kinds of complex questions encountered. The paper describes how the PEC has responded to substantive ethical issues raised within the TREAT-NMD consortium and how it has provided a wider resource for any concerned parent, patient, or clinician to ask a question of ethical concern. Issues raised range from science related ethical issues, issues related to hereditary neuromuscular diseases and the new therapeutic approaches and questions concerning patients rights in the context of patient registries and bio-banks. We conclude by recommending the PEC as a model for similar research contexts in rare diseases.

[Results registries for clinical trials--a milestone on the way to transparency in clinical research?]

Publication bias, i.e., the publication of trial results depending on the nature and direction of results, is a significant problem in healthcare, as it leads to a biased view of the treatment options available. Furthermore, publication bias hampers the adequate planning and conduct of future clinical trials. One proposal to reduce publication bias is the registration of trials and trial results. Whereas the registration of trials at inception is largely accepted and partly established, the registration of trial results is still being intensively discussed. Open issues particularly refer to legal obligations in the registration of trial results as well as to the nature and extent of their presentation. Whilst in the United States a comprehensive legal regulation on results registration has already been implemented, compulsory registration in Europe is still at a preliminary stage. The present paper describes the status quo of results registries, discusses registration requirements, and outlines the need to develop methods for the handling of results registries.

Inadequate dissemination of phase I trials: a retrospective cohort study

BACKGROUND

Drug development is ideally a logical sequence in which information from small early studies (Phase I) is subsequently used to inform and plan larger, more definitive studies (Phases II-IV). Phase I trials are unique because they generally provide the first evaluation of new drugs in humans. The conduct and dissemination of Phase I trials have not previously been empirically evaluated. Our objective was to describe the initiation, completion, and publication of Phase I trials in comparison with Phase II-IV trials.

METHODS AND FINDINGS

We reviewed a cohort of all protocols approved by a sample of ethics committees in France from January 1, 1994 to December 31, 1994. The comparison of 140 Phase I trials with 304 Phase II-IV trials, showed that Phase I studies were more likely to be initiated (133/140 [95%] versus 269/304 [88%]), more likely to be completed (127/133 [95%] versus 218/269 [81%]), and more likely to produce confirmatory results (71/83 [86%] versus 125/175 [71%]) than Phase II-IV trials. Publication was less frequent for Phase I studies (21/127 [17%] versus 93/218 [43%]), even if only accounting for studies providing confirmatory results (18/71 [25%] versus 79/125 [63%]).

CONCLUSIONS

The initiation, completion, and publications of Phase I trials are different from those of other studies. Moreover, the results of these trials should be published in order to ensure the integrity of the overall body of scientific knowledge, and ultimately the safety of future trial participants and patients.

Ethical issues in psychiatric research on children and adolescents

Psychiatric research on children and adolescents is ethically justified by the need to reduce the burden that mental illnesses place on young people, their families, and society. Such research must be conducted with careful attention to the ethical principles of beneficence, justice, and respect for persons. Child and adolescent psychiatrists who collaborate on research trials or advise patients and families about research participation should consider nine domains when evaluating the ethical acceptability of particular protocols. These domains include scientific merit and design; expertise, commitment, and integrity; risks and benefits; confidentiality; participant selection and recruitment; informed consent and decisional capacity; incentives; institution and peer/professional review; and data presentation. Special ethical issues in child and adolescent psychiatry research concern the use of randomized, controlled treatment trials; the informed consent process for research involving adolescents; the therapeutic misconception; and conflicts of interest in physician referrals.

Registering randomized clinical trials and the case for CONSORT

Recent controversies in medical research and the increasing reliance on randomized clinical trials to inform evidence-based practice have prompted coordinated attempts to standardize reporting and register information about trials for consistency and transparency. The Consolidated Standards of Reporting Trials guidelines (D. G. Altman et al., 2001) and trial registry are described in this article, and the implications for clinical and experimental research in psychopharmacology are discussed.

The ICMJE and URM: Providing Independent Advice for the Conduct of Biomedical Research and Publication

The International Committee of Medical Journal Editors (ICMJE) is a working group of editors of selected medical journals that meets annually. Founded in Vancouver, Canada, in 1978, it currently consists of 11 member journals and a representative of the US National Library of Medicine. The major purpose of the Committee is to address and provide guidance for the conduct and publishing of biomedical research and the ethical tenets underpinning these activities. This advice is detailed in the Committee's Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication (URM).Recently, the ICMJE has adopted an interventionist role to ensure transparency of conflict of interest revelations in the conduct and publication of industry supported research. It also pursues a policy for the lodgement with trial registries of specified details of Phase III clinical trials. Failure to comply would jeopardise publication of trial outcomes in ICMJE member journals. This policy has resulted in the coming on stream of trial registries, international agreement on trial minimal datasets and compliance with trial registration requirements.

A model clinical trials agreement

The Department of Health's new model agreement raises questions about the NHS's relation with industry