Use of data from registered clinical trials to identify gaps in health research and development

Human papillomavirus (HPV) trials: A cross-sectional analysis of clinical trials registries

Every clinical trial must be registered in a publicly accessible trial registry before enrollment of the first participant. Prospectively registering clinical trials before enrolling participants helps to prevent unethical research misconduct from occurring, duplication of research and increases transparency in research. The aim of this study was to provide cross-sectional survey analysis of planned, ongoing and completed human papillomavirus (HPV) clinical trials conducted worldwide. We searched the International Clinical Trials Registry Platform (ICTR) for registered HPV trials on 5 March 2023. Two authors independently extracted data including name of the clinical trial registry, location of the trial, recruitment status of the trial, gender of participants, phase of the trial, and type of trial sponsor. We used Microsoft Excel to perform descriptive analysis. The search yielded 1632 trials registered between 1999 and 2023. Most of the trials were registered in ClinicalTrials.gov and were registered retrospectively. We also found that most trials were conducted in North America, in recruiting stage, and indicated "not applicable" under the phase of the trial field. Finally, most trials were sponsored by hospitals. Our study found that there are many HPV clinical trials registered in different clinical trial primary registries around the world. However, many of the trials were registered retrospectively instead of the required prospectively and some had missing fields. Therefore, there is a need for registries to promote prospective trial registration and completion of all fields during the registration process.

Characterization of clinical trials in Ecuador and their association with disease burden: Are there research gaps?

This study offers a detailed analysis of clinical trials conducted in Ecuador from 2010 to 2022 to assess alignment with the country's disease burden as indicated by the Global Burden of Disease study. Utilizing data from five registries, including ARCSA and Clinicaltrials.gov, we analyzed characteristics and coverage of 75 CTs after removing duplicates and ineligible studies. Findings reveal a 50% research gap across disease groups, with neoplasms being the only category matching disease burden. The scarcity of clinical research highlights the disparity between CTs and prevalent diseases such as cardiovascular and kidney diseases, diabetes, and other non-communicable conditions. Our results underscore the urgent need for increased clinical research investment addressing these critical health challenges in Ecuador.

Iran's research prioritization: Are we meeting the goals? A study based on clinical trial registry data

The prioritization of research topics in the health domain is a critical step toward channelling efforts and resources into areas that have received less attention. The objective of this study is to evaluate the implementation of research priorities determined at the national level within Iran for the period spanning five years between 2009 and 2013. We extracted the required data from the Iranian Registry of Clinical Trials (IRCT) website. Then we conducted a matching process between the titles of trials registered in the IRCT until December 3rd, 2013, and the list of national health research priorities in the domains of communicable and non-communicable diseases. The latter was compiled and regulated by the Research and Technology Deputy of the Ministry of Health since 2008. Out of the total 5,049 clinical trials registered in IRCT, 92.3% were carried out within the domain of non-communicable diseases, while 6.1% pertained to the field of communicable diseases and the remaining 1.3% in other fields. 56.4% of the clinical trials conducted in the field of communicable diseases and 32.8% of those conducted in the field of non-communicable diseases were consistent with the research priorities determined in these two fields. During the five-year period of the prioritization goal, there was no significant improvement in adherence to the list of priorities compared to the previous five-year period. Furthermore, certain priorities were neglected within both areas during these periods. It is possible to evaluate the effectiveness of research prioritization using the data obtained from the registration centers of clinical trials. Our study has revealed that the list of priorities has not garnered adequate attention from the research community within the country. Hence, remedial measures are imperative to ensure the priorities are given more attention after publication.

Global Equity in Clinical Trials: An ASCO Policy Statement

ASCO is a global professional society representing more than 50,000 physicians, other health care professionals, and advocates in over 100 countries specializing in cancer treatment, diagnosis, prevention, and advocacy. ASCO strives, through research, education, and promotion of the highest quality of patient care, to create a world where cancer is prevented or cured, and every survivor is healthy. In this pursuit, health equity remains the guiding institutional principle that applies to all its activities across the cancer care continuum. This ASCO policy statement emphasizes the urgent need for global equity in clinical trials, aiming to enhance access and representation in cancer research as it not only improves cancer outcomes but also upholds principles of fairness and justice in health care.

Facilitating audits of clinical trial data using documents of the Food and Drug Administration

The Medical Review document of the FDA is a rich source of data about clinical trials underlying the approval of a given drug. There are also other sources of information about clinical trials, such as trial registries and publications. However the data in the various sources may be erroneous or discrepant, and therefore there have been calls for audits of data in trial registries, in particular. The data in the Medical Review documents could be used as a source, to cross check data from other sources. However, it is extremely cumbersome to access the data in this document. We have analyzed the summary ‘Table of Clinical Studies’ of forty five Medical Reviews, and note significant differences in what information is presented in this table. We outline the details of an informative template Table, that would facilitate audits.

Planned, ongoing and completed tuberculosis treatment trials in Brazil, Russia, India, China and South Africa: a 2019 cross-sectional descriptive analysis

Tuberculosis (TB) remains a deadly challenge globally and Brazil, Russia, India, China and South Africa (BRICS) are among the countries with the highest TB burden. The objective of this study is to identify and describe ongoing, planned and completed TB trials conducted in the BRICS countries registered in WHO-International Clinical Trial Registry Platform (WHO-ICTRP); to report selective outcome reporting by comparing primary outcomes in published trials with their prespecified outcomes in registry records and to evaluate the time to publication.

METHODS AND ANALYSIS

We searched the WHO-ICTRP portal (20 January 2019) and the Russian Federation Registry (30 March 2019) to identify TB trials conducted in BRICS countries. We included only registered clinical trials conducted wholly in BRICS countries or with at least one recruitment centre in one of the BRICS countries that were investigating TB treatment.

RESULTS

The search of the WHO-ICTRP yielded 408 trials and additional 32 trials were identified from the Russian registry. Of those, 253 were included in the analysis. We found that 77 trials were multicountry trials, followed by trials in China (55), India (53), South Africa (34), Russia (23) and Brazil (11). 163 trials were registered prospectively, 69 retrospectively and 21 trials had no registration status. Most trials (207) evaluated TB treatment, followed by 29 behaviour change interventions, 13 nutritional supplementation, 4 surgical treatment and 2 assessing rehabilitation. Based on ICJME recommendation of publishing 12 months after completion of trial, we found that 156 trials were completed 12 or more months by date and 101 trials had publications. Thirty-one of the 101 trials with publication had evidence of selective outcome reporting. The median time to publication was 25 months (IQR 15-37) from the time of anticipated end date stated in the registry.

CONCLUSION

TB trials conducted in BRICS countries are collaborative, mostly drug treatment oriented, potentially affecting policies. Selective outcome reporting remains a problem both for prospectively and retrospectively registered trials, only small fraction of which gets to publication.

Inequities in cancer drug development in terms of unmet medical need

This study measures inequality and inequity in the distribution of clinical trials on cancer drug development between 1996 and 2016, comparing the number of clinical trials with cancer need, proxied by prevalence, incidence, or survival rates for both rare and non-rare cancers. We leverage a unique global database of clinical trials activity and costs between 1996 and 2016, constructed for 227 different cancer types to measure for rare and non-rare cancers: i) inequalities and inequity of clinical trial activity, considering all trials as well as split by R&D stage; ii) inequalities and inequity in R&D investment proxied by trial enrollment and duration; iii) evolution of inequity over time. Inequalities are measured with concentration curves and indices and inequities measured with the health inequity index. We find four important results. First, we show pro-low need inequity across cancer types for both rare and non-rare cancers, for all need proxies. Second, we show inequity differs across R&D stages and between rare and non-rare cancers. The distribution of clinical trials for non-rare cancers disproportionately favors low-need non-rare cancers from earlier to later stages of R&D, whilst for rare cancers this only occurs in Phase 2 trials. Third, inequity analyses in R&D investment show that only trial enrollment for rare cancers and trial duration for non-rare cancers are disproportionately concentrated among low-need cancers. Finally, while pro-low need inequity has persisted between 1996 and 2016 for non-rare cancers, it has faded for rare cancers post-EU orphan drugs' legislation.

Discrepancies between FDA documents and ClinicalTrials.gov for Orphan Drug-related clinical trial data

Clinical trial registries such as ClinicalTrials.gov (CTG) hold large amounts of data regarding trials. Drugs for rare diseases are known as orphan drugs (ODs), and it is particularly important that trials for ODs are registered, and the data in the trial record are accurate. However, there may be discrepancies between trial-related data that were the basis for the approval of a drug, as available from Food and Drug Administration (FDA) documents such as the Medical Review, and the data in CTG. We performed an audit of FDA-approved ODs, comparing trial-related data on phase, enrollment, and enrollment attribute (anticipated or actual) in such FDA documents and in CTG. The Medical Reviews of 63 ODs listed 422 trials. We used study identifiers in the Medical Reviews to find matches with the trial ID number, 'Other ID' or 'Acronyms' in CTG, and identified 202 trials that were registered with CTG. In comparing the phase data from the 'Table of Clinical Studies' of the Medical Review, with the data in CTG, there were exact matches in only 75% of the cases. The enrollment matched only in 70% of the cases, and the enrollment attribute in 91% of the cases. A similar trend was found for the sub-set of pivotal trials. Going forward, for all trials listed in a registry, it is important to provide the trial ID in the Medical Review. This will ensure that all trials that are the basis of a drug approval can be swiftly and unambiguously identified in CTG. Also, there continue to be discrepancies in trial data between FDA documents and CTG. Data in the trial records in CTG need to be updated when relevant.

Secondary analysis of data from a core outcome set for burns demonstrated the need for involvement of lower income countries

Objective

To compare the views of participants from different income-status countries on outcome selection for a burn care Core Outcome Set (COS).

Methods

A retrospective analysis of data collected during a two round Delphi survey to prioritise the most important outcomes in burn care research.

Results

There was considerable agreement between participants from low- and middle-income countries (LMICs) and high-income countries (HICs) across outcomes. The groups agreed on 91% of 88 outcomes in round 1 and 92% of 100 in round 2. In cases of discordance, the consensus of participants from LMICs was to include the outcome and for participants from HICs to exclude. There was also considerable agreement between the groups for the top-ten ranking outcomes. Discordance in outcome prioritisation gives an insight into the different values clinicians from LMICs place on outcomes compared to those from HICs. Limitations of the study were that outcome rankings from international patients were not available. Healthcare professionals from LMICs were not involved in the final consensus meeting.

Conclusion

COS developers should consider the need for a COS to be global at protocol stage. Global COS should include equal representation from both LMICs and HICs at all stages of development.

Challenges in clinical trials for children and young people

There is a well-known knowledge gap regarding the efficacy and safety of medicines in children of all ages and children are often treated with medicines off-label. Children are thus deprived of treatment based on the same quality of information that guides treatment in adults. The knowledge gap regarding efficacy and safety of medicines in children has been acknowledged by authorities and is reflected in legislation both in North America and in the European Union. Recent reports on the effects of legislation indicates that paediatric clinical trials remain a challenge.Paediatric clinical trials are needed in the entire developmental age spectrum and are especially needed in certain therapy areas. Paediatric clinical trials have special features compared with trials in adults, and these need to be taken into account. These special features include scientific issues related to small samples and heterogeneity, the consent/assent procedure, the need for age-appropriate study information, specific outcomes and safety issues related to development and maturation. Competence in paediatric clinical trials is required in both designing, planning, co-ordinating and organising paediatric clinical trials, as well as research infrastructure and networks to increase power and disseminate information and expert advice. Strengthening of paediatric clinical research is essential to facilitate generating the data that will let children enjoy new medical advances in a similar manner as adults.

Patient income and health innovation

This study analyzes the relationship between the number of clinical trials in a disease area, the health losses from that disease, and the average income of people suffering from it. Average patient income appears strongly predictive of the number of clinical trials, whether funded by industry or not. We are able to precisely estimate the relationship between income and the number of trials and to identify both (a) the specific diseases that appear to be underfunded relative to their harm to human health and (b) the amount of additional funding required to bring innovation investment up to the present average.

There's No Harm in Talking: Re-Establishing the Relationship Between Theological and Secular Bioethics

Theological and secular voices in bioethics have drifted into separate silos. Such a separation results in part from (1) theologians focusing less on conveying ideas in ways that contribute to a pluralistic and public bioethical discourse and (2) the dwindling receptivity of religious arguments within secular bioethics. This essay works against these drifts by putting forward an argument that does not bounce around a religious echo-chamber, but instead demonstrates how insights of Christian anthropology can be meaningfully responsive to secular bioethics' rightful concerns with inequality and injustice. We offer core concepts from Christian bioethics that encourage dialogue with secular and theological bioethicists. The theologically-grounded concepts, human dignity, sin, and the common good, provide intellectual resources to address major areas of bioethical concern that remain unresolved.

Relationship between clinical trials and disease burden of India: A cross-sectional study

Background:

Research output/efforts in a country should be reflective of the disease burden. India is a site for several national and multinational clinical trials. However, whether clinical trials performed in India reflect the disease burden is not well known.

Objectives:

The aim of this study was to evaluate the relationship between disease burden and clinical trials performed in India.

Materials and Methods:

We extracted data on the disease burden from the World Health Organization (WHO) website and on characteristics of clinical trials performed in India from the Clinical Trial Registry of India (CRTI). The correlation between disease burden parameters of overall mortality, disability-adjusted life years (DALYs), years lost due to disability (YLD) and years of life lost (YLL), and the frequency of clinical trials associated with a particular disease was assessed. Additional subgroup analysis according to the number of trial centers, study phase, and medicine type was also performed.

Results:

Only 18% of clinical trials addressed top 10 diseases associated with 68.3% of overall mortality, and 8% of clinical trials addressed top 10 diseases associated with 52.3% of DALYs. Similarly, 16% of clinical trials addressed top 10 diseases associated with 53.2% YLDs. Furthermore, top 10 diseases associated with 65.9% of YLLs were addressed in only 8% of ongoing clinical trials. The overall correlation between any disease burden parameters with the diseases being explored in clinical trials was poor.

Conclusion:

There is a mismatch between diseases for which clinical trials are happening in the India and the disease burden of India. Measures need to be taken to fulfill this gap between demand and need.

Prioritising health research in KwaZulu-Natal: has the research conducted met the research needs?

Background

The KwaZulu-Natal (KZN) Health Act of 2009 mandates the Provincial Health Research and Ethics Committee to develop health research priorities for the province. During 2013, the KZN Department of Health embarked on a research prioritisation process for the province. Priority research questions were generated by an inclusive process, in which a variety of stakeholders in health research in the province were engaged. The aim of this study was to determine whether research conducted at public health facilities in KZN between 01 January 2014 and 31 March 2017 met the research priorities of the province developed through the provincial research prioritisation process of 2013.

Methods

This was a mixed methods study. Qualitative thematic analysis was used to categorise priority research questions generated in the priority-setting process and the titles of research projects conducted after that process into themes. Quantitative analysis was used to determine the correlation between themes of the priority questions, and those of the research projects conducted after the prioritisation exercise. Statistical Package for Social Science version 25 was used to analyse the data.

Results

In 72% of thematic areas, there were disproportionately more priority questions than there were research projects conducted. There is thus a large disjuncture between the priorities developed through the provincial research prioritisation process of 2013 and the research projects conducted after that process in terms of major research areas.

Conclusions

Ensuring that research conducted responds to priority questions raised is important because it ensures that research responds to locally important issues and to the concerns of local actors. Local health managers, communities and researchers should work together to ensure that the research conducted in their areas respond to the research priorities of those areas. Health Research Committees and local ethics committees can play important roles in facilitating the responsiveness to research priorities.

Evidence maps: a tool to guide research agenda setting

A surprisingly huge proportion of medical research still shows poor quality in design, conduct and analysis, leading to far from optimal robustness of findings and validity of conclusions. Research waste remains a problem caused by a number of reasons. Asking the wrong research questions and ignoring the existing evidence are possible preventable ones. Evidence maps are tools that may aid in guiding clinical investigators and help in agenda setting of future research. In this article, we explain how they serve such a goal and outline the steps required to build effective evidence maps.

A scoping review describes methods used to identify, prioritize and display gaps in health research

BACKGROUND AND OBJECTIVES

Different methods to examine research gaps have been described, but there are still no standard methods for identifying, prioritizing, or reporting research gaps. This study aimed to describe the methods used to identify, prioritize, and display gaps in health research.

METHODS

A scoping review using the Arksey and O'Malley methodological framework was carried out. We included all study types describing or reporting on methods to identify, prioritize, and display gaps or priorities in health research. Data synthesis is both quantitative and qualitative.

RESULTS

Among 1,938 identified documents, 139 articles were selected for analysis; 90 (65%) aimed to identify gaps, 23 (17%) aimed to determine research priorities, and 26 (19%) had both aims. The most frequent methods in the review were aimed at gap identification and involved secondary research, which included knowledge synthesis (80/116 articles, 69%), specifically systematic reviews and scoping reviews (58/80, 73%). Among 49 studies aimed at research prioritization, the most frequent methods were both primary and secondary research, accounting for 24 (49%) reports. Finally, 52 (37%) articles described methods for displaying gaps and/or priorities in health research.

CONCLUSION

This study provides a mapping of different methods used to identify, prioritize, and display gaps or priorities in health research.

Does global drug innovation correspond to burden of disease? The neglected diseases in developed and developing countries

Although it is commonly argued that there is a mismatch between drug innovation and disease burden, there is little evidence on the magnitude and direction of such disparities. In this paper, we measure inequality in innovation, by comparing research and development activity with population health and gross domestic product data across 493 therapeutic indications to globally measure: (a) drug innovation, (b) disease burden, and (c) market size. We use concentration curves and indices to assess inequality at two levels: (a) broad disease groups and (b) disease subcategories for both 1990 and 2010. For some top burden disease subcategories (i.e., cardiovascular and circulatory diseases, neoplasms, and musculoskeletal disorders), innovation is disproportionately concentrated in diseases with high disease burden and large market size, whereas for others (i.e., mental and behavioral disorders, neonatal disorders, and neglected tropical diseases) innovation is disproportionately concentrated in low burden diseases. These inequalities persisted over time, suggesting inertia in pharmaceutical research and development in tackling the global health challenges. Our results confirm quantitatively assertions about the mismatch between disease burden and pharmaceutical innovation in both developed and developing countries and highlight the disease areas for which morbidity and mortality remain unaddressed.

Adherence to clinical trial registration in countries of Latin America and the Caribbean, 2015

Objective

To determine the prevalence of clinical trial registration in the International Clinical Trial Registry Platform (ICTRP) for studies from Latin America and the Caribbean (LAC) and to identify the key characteristics that lead to prospective and retrospective registration.

Methods

A cross-sectional study identified published, clinical trial studies through a search of PubMed, LILACS (Latin American and Caribbean Center on Health Sciences Information), and the Cochrane Central Register of Controlled Trials. Studies were included if published on 1 January – 31 December 2015, at least one author was affiliated with at least one LAC country, the clinical trial was conducted in at least one LAC site, and the full text of the article was available. A manual search of reference lists was also conducted. ICTRP registration information and key trial characteristics were compared.

Results

Of 1 502 CT references that met inclusion criteria, 297 were randomly-selected, 90.9% of which were published in English, 65% from Brazil, and 76.8% had a LAC author as the first author. The proportion of CT registered in the ICTRP was 59.9 %, of which 51.7% were registered prospectively. Clinicaltrials.gov was most frequently used registry (84.8%), followed by the Registro Brasileiro de Ensaios Clínicos and the Registro Público Cubano de Ensayos Clínicos. Key characteristics that favored registration were being in study phase 3 or 4 or being a multi-center study. Data was compared to a similar study from 2013 that reported a registration rate of only 19.8%.

Conclusions

Registration adherence and prospective registration have increased in LAC in recent years, but the proportion of unregistered CT remains high. While there are still many challenges to overcome, the adherence strategies implemented in recent years have proven effective.

A comparison between health research output and burden of disease in Arab countries: evidence from Palestine

BACKGROUND

Research conducted on conditions responsible for the greatest disease burden should be given the highest priority, particularly in resource-limited settings. The present study aimed to assess the research output in relation to disease burden in Palestine and to identify the conditions which are under- or over-investigated, if any.

METHODS

We searched PubMed and Scopus for reports of original research relevant to human health or healthcare authored by researchers affiliated with Palestinian institutions and published between January 2000 and December 2015. We categorised the condition studied in included articles using the Global Burden of Disease (GBD) taxonomy. Data regarding burden of disease (percentage of deaths and disability-adjusted life years (DALYs)) was obtained from the Palestine profile in the GBD study. We examined the degree of discordance between the observed number of published articles for each disease/condition with the expected number based on the proportion of disease burden of that disease/condition.

RESULTS

Our search identified 2469 potentially relevant records, from which 1650 were excluded following the screening of titles and abstracts. Of the remaining 819 full-text articles, we included 511 in our review. Communicable (infectious) diseases (n = 103; 20%) was the condition with the highest number of published studies. However, cancer (n = 15; 3%) and chronic respiratory diseases (n = 15; 3%) were the conditions with the lowest number of published studies. Research output was poorly associated with disease burden, irrespective of whether it was measured in terms of DALYs (rho = -0.116, P = 0.7) or death (rho = 0.217, P = 0.5). Cardiovascular disease, cancer, and maternal and neonatal deaths accounted for more than two-thirds of the total deaths in Palestine (67%), but were infrequently addressed (23%) in published articles.

CONCLUSIONS

There is evidence of research waste measured by a mismatch between the health burden of certain diseases/conditions and the number of published research reports on those diseases/conditions in Palestine. A national research priority-setting agenda should be developed to meet the local community's need for quality evidence to implement independent and informed health policies.

A mapping of 115,000 randomized trials revealed a mismatch between research effort and health needs in non-high-income regions

BACKGROUND

Concerns exist as to whether the allocation of resources in clinical research is aligned with public health needs. We evaluated the alignment between the effort of clinical research through the conduct of randomized controlled trials (RCTs) and health needs measured as the burden of diseases for all regions and a broad range of diseases.

METHODS

We grouped countries into seven regions and diseases into 27 groups. We mapped all RCTs initiated between 2006 and 2015 that were registered at the WHO International Clinical Trials Registry Platform to regions and diseases. The burden of diseases in 2005 was mapped as disability-adjusted life years (DALYs), based on the 2010 Global Burden of Diseases study. Within regions, we defined a research gap when the proportion of RCTs concerning a disease in the region was less than half the relative burden of the disease.

RESULTS

We mapped 117,180 RCTs planning to enroll 42.6 million patients and 2,220 million DALYs. In high- versus non-high-income countries, 130.9 versus 6.9 RCTs per million DALYs were conducted. We did not identify any research gap in high-income countries. We identified research gaps for all other regions. In particular, for Sub-Saharan Africa, we identified research gaps for common infectious diseases (CID) and neonatal disorders (ND): 5.8% (95% uncertainty interval 4.7-6.9) and 2.0% (0.9-4.5) of RCTs in Sub-Saharan Africa concerned CID and ND, although these diseases represented 22.9% and 11.6% of the burden in the region, respectively. For South Asia, we identified research gaps for the same two groups of diseases.

CONCLUSIONS

In non-high-income regions, the conduct of RCTs was misaligned with the distribution of major causes of burden, in particular infectious diseases and neonatal disorders in Sub-Saharan Africa and South Asia.

Action plan for optimizing the design of clinical trials in chronic kidney disease

High-quality clinical trials are the cornerstone of evidence-based prevention and treatment of a disease, but nephrology has a strikingly weak base of such trials. Building the evidence base to improve outcomes for people with a kidney disease, therefore, requires both greater quantity and quality of clinical trials. To address these issues, we propose that we aim to enroll 30% of people with chronic kidney disease in trials by 2030. Goal 1: Strongly encourage and promote the conduct of clinical trials in people with chronic kidney disease to increase the number of clinical trials conducted. Goal 2: Optimize the design of clinical trials in people with chronic kidney disease. Goal 3: Increase the capacity for conducting clinical trials in people with chronic kidney disease.

Iranian clinical trials: An analysis of registered trials in International Clinical Trial Registry Platform (ICTRP)

OBJECTIVE

This study investigated and analyzed Iranian clinical trials registered in the ICTRP portal by the end of 2015. The goal was to determine which diseases are currently being studied and whether these are diseases that carry the greatest burden of disease according to regional and WHO statistics.

MATERIALS AND METHODS

Information on clinical trials carried out in Iran was downloaded from the portal of the International Clinical Trials Registry website. By the end of 2015, 10,341 studies were registered from Iran. After removing duplicate and observational studies, 10,211 studies remained for analysis. The 2016 edition of the International Classification of Diseases was used to classify the diseases.

RESULTS

The frequency of studies was found to be mental and behavioral disorders (10.44%), diseases of the genitourinary system (10.2%), and endocrine, nutritional, and metabolic diseases (10.01%). Gastrointestinal and dermatologic diseases made up more than 12% of studies, but bear only 0.84% of the burden of disease in Iran.

CONCLUSION

The results showed that, despite an increase in registration of clinical trials in Iran, most studies registered were conducted on diseases, which form only a small percentage of the total disease burden of the country.

Automatic classification of registered clinical trials towards the Global Burden of Diseases taxonomy of diseases and injuries

BACKGROUND

Clinical trial registries may allow for producing a global mapping of health research. However, health conditions are not described with standardized taxonomies in registries. Previous work analyzed clinical trial registries to improve the retrieval of relevant clinical trials for patients. However, no previous work has classified clinical trials across diseases using a standardized taxonomy allowing a comparison between global health research and global burden across diseases. We developed a knowledge-based classifier of health conditions studied in registered clinical trials towards categories of diseases and injuries from the Global Burden of Diseases (GBD) 2010 study. The classifier relies on the UMLS® knowledge source (Unified Medical Language System®) and on heuristic algorithms for parsing data. It maps trial records to a 28-class grouping of the GBD categories by automatically extracting UMLS concepts from text fields and by projecting concepts between medical terminologies. The classifier allows deriving pathways between the clinical trial record and candidate GBD categories using natural language processing and links between knowledge sources, and selects the relevant GBD classification based on rules of prioritization across the pathways found. We compared automatic and manual classifications for an external test set of 2,763 trials. We automatically classified 109,603 interventional trials registered before February 2014 at WHO ICTRP.

RESULTS

In the external test set, the classifier identified the exact GBD categories for 78 % of the trials. It had very good performance for most of the 28 categories, especially "Neoplasms" (sensitivity 97.4 %, specificity 97.5 %). The sensitivity was moderate for trials not relevant to any GBD category (53 %) and low for trials of injuries (16 %). For the 109,603 trials registered at WHO ICTRP, the classifier did not assign any GBD category to 20.5 % of trials while the most common GBD categories were "Neoplasms" (22.8 %) and "Diabetes" (8.9 %).

CONCLUSIONS

We developed and validated a knowledge-based classifier allowing for automatically identifying the diseases studied in registered trials by using the taxonomy from the GBD 2010 study. This tool is freely available to the research community and can be used for large-scale public health studies.

Why Most Clinical Research Is Not Useful

John Ioannidis argues that problem base, context placement, information gain, pragmatism, patient centeredness, value for money, feasibility, and transparency define useful clinical research. He suggests most clinical research is not useful and reform is overdue.

Differential Globalization of Industry- and Non-Industry-Sponsored Clinical Trials

BACKGROUND

Mapping the international landscape of clinical trials may inform global health research governance, but no large-scale data are available. Industry or non-industry sponsorship may have a major influence in this mapping. We aimed to map the global landscape of industry- and non-industry-sponsored clinical trials and its evolution over time.

METHODS

We analyzed clinical trials initiated between 2006 and 2013 and registered in the WHO International Clinical Trials Registry Platform (ICTRP). We mapped single-country and international trials by World Bank's income groups and by sponsorship (industry- vs. non- industry), including its evolution over time from 2006 to 2012. We identified clusters of countries that collaborated significantly more than expected in industry- and non-industry-sponsored international trials.

RESULTS

119,679 clinical trials conducted in 177 countries were analysed. The median number of trials per million inhabitants in high-income countries was 100 times that in low-income countries (116.0 vs. 1.1). Industry sponsors were involved in three times more trials per million inhabitants than non-industry sponsors in high-income countries (75.0 vs. 24.5) and in ten times fewer trials in low- income countries (0.08 vs. 1.08). Among industry- and non-industry-sponsored trials, 30.3% and 3.2% were international, respectively. In the industry-sponsored network of collaboration, Eastern European and South American countries collaborated more than expected; in the non-industry-sponsored network, collaboration among Scandinavian countries was overrepresented. Industry-sponsored international trials became more inter-continental with time between 2006 and 2012 (from 54.8% to 67.3%) as compared with non-industry-sponsored trials (from 42.4% to 37.2%).

CONCLUSIONS

Based on trials registered in the WHO ICTRP we documented a substantial gap between the globalization of industry- and non-industry-sponsored clinical research. Only 3% of academic trials but 30% of industry trials are international. The latter appeared to be conducted in preferentially selected countries.

Trends in global clinical trial registration: an analysis of numbers of registered clinical trials in different parts of the world from 2004 to 2013

OBJECTIVES

To analyse developments (and their causes) in the number and proportion of clinical trials that were registered in different parts of the world after the International Committee of Medical Journal Editors (ICMJE) announced in 2004 that it would require registration of clinical trials as a condition for publication.

SETTING

The International Clinical Trials Registry Platform (ICTRP).

DESIGN

The ICTRP database was searched for all clinical trials that were registered up to 31 December 2013.

RESULTS

The ICTRP database contained data on 186,523 interventional clinical trials. The annual number of registered clinical trials increased from 3294 in 2004 to 23,384 in 2013. Relative to the number of clinical trial research publications, the global number of registered clinical trials increased fivefold between 2004 and 2013, rising particularly strongly between 2004 and 2005. In certain regions, especially Asia, the annual number of registered trials increased more gradually and continued to increase up to 2013. In India and Japan, two countries with marked but more gradual increases, these increases only happened after several local measures were implemented that encouraged and enforced registration. In most regions, there was a trend toward trials being registered at local registries.

CONCLUSIONS

Clinical trial registration has greatly improved transparency in clinical trial research. However, these improvements have not taken place equally in all parts of the world. Achieving compliance with registration requires a coalescence of global and local measures, and remains a key challenge in many countries. Poor quality of registered trial data and the inaccessibility of trial protocols, results and participant-level data further undermine the potential benefits of clinical trial registration. National and regional registries and the ICTRP have played a leading role in achieving the successes of trial registration to date and should be supported in addressing these challenges in the future.

The evolution in registration of clinical trials: a chronicle of the historical calls and current initiatives promoting transparency

PURPOSE

Quality of care is strongly influenced by evidence-based medicine, a large part of which is based on results obtained from clinical trials. If trials are conducted in secret, patient safety is at risk. Several mandates-legal, editorial, financial, and ethical-have tried to influence the disclosure of clinical trials, first by encouraging registration in publicly accessible registers and, second, by calling for the publication of results. Not all these initiatives have reached high rates of compliance, but the succession of national and international events over a few years gave an important boost to information disclosure. This article provides a chronicle of the succession of the events, from the historical calls to the recent EMA policy and WHO statement, and public consultations requested by the NIH, and the HHS, which will inevitably change the international panorama. The path of these new policies is moving towards more supervised clinical research. Individual scientific institutions can also contribute, at the local level, to such an ethical endeavor as is improving research transparency, by disclosing information on the trials coordinated by their own researchers.

RESULTS

The way is long and complex, but, if everyone contributes there could be a prompt, worldwide diffusion of the findings of clinical trials, and therefore a more possible evidenced-based medicine.

Poverty-related and neglected diseases - an economic and epidemiological analysis of poverty relatedness and neglect in research and development

Background

Economic growth in low- and middle-income countries (LMIC) has raised interest in how disease burden patterns are related to economic development. Meanwhile, poverty-related diseases are considered to be neglected in terms of research and development (R&D).

Objectives

Developing intuitive and meaningful metrics to measure how different diseases are related to poverty and neglected in the current R&D system.

Design

We measured how diseases are related to economic development with the income relation factor (IRF), defined by the ratio of disability-adjusted life-years (DALYs) per 100,000 inhabitants in LMIC versus that in high-income countries. We calculated the IRF for 291 diseases and injuries and 67 risk factors included in the Global Burden of Disease Study 2010. We measured neglect in R&D with the neglect factor (NF), defined by the ratio of disease burden in DALYs (as percentage of the total global disease burden) and R&D expenditure (as percentage of total global health-related R&D expenditure) for 26 diseases.

Results

The disease burden varies considerably with the level of economic development, shown by the IRF (median: 1.38; interquartile range (IQR): 0.79–6.3). Comparison of IRFs from 1990 to 2010 highlights general patterns of the global epidemiological transition. The 26 poverty-related diseases included in our analysis of neglect in R&D are responsible for 13.8% of the global disease burden, but receive only 1.34% of global health-related R&D expenditure. Within this group, the NF varies considerably (median: 19; IQR: 6–52).

Conclusions

The IRF is an intuitive and meaningful metric to highlight shifts in global disease burden patterns. A large shortfall exists in global R&D spending for poverty-related and neglected diseases, with strong variations between diseases.

The quality of registration of clinical trials: still a problem

INTRODUCTION

The benefits of clinical trials registration include improved transparency on clinical trials for healthcare workers and patients, increased accountability of trialists, the potential to address publication bias and selective reporting, and possibilities for research collaboration and prioritization. However, poor quality of information in registered records of trials has been found to undermine these benefits in the past. Trialists' increasing experience with trial registration and recent developments in registration systems may have positively affected data quality. This study was conducted to investigate whether the quality of registration has improved.

METHODS

We repeated a study from 2009, using the same methods and the same research team. A random sample of 400 records of clinical trials that were registered between 01/01/2012 and 01/01/2013 was taken from the International Clinical Trials Registry Platform (ICTRP) and assessed for the quality of information on 1) contact details, 2) interventions and 3) primary outcomes. Results were compared to the equivalent assessments from our previous study.

RESULTS

There was a small and not statistically significant increase from 81.0% to 85.5% in the percentage of records that provided a name of a contact person. There was a significant increase from 68.7% to 74.9% in the number of records that provided either an email address or a telephone number. There was a significant increase from 44.2% to 51.9% in the number of intervention arms that were complete in registering intervention specifics. There was a significant increase from 38.2% to 57.6% in the number of primary outcomes that were specific measures with a meaningful timeframe. Approximately half of all trials continued to be retrospectively registered.

DISCUSSION

There have been small but significant improvements in the quality of registration since 2009. Important problems with quality remain and continue to constitute an impediment to the meaningful utilization of registered trial information.

Mapping of available health research and development data: what's there, what's missing, and what role is there for a global observatory?

The need to align investments in health research and development (R&D) with public health demands is one of the most pressing global public health challenges. We aim to provide a comprehensive description of available data sources, propose a set of indicators for monitoring the global landscape of health R&D, and present a sample of country indicators on research inputs (investments), processes (clinical trials), and outputs (publications), based on data from international databases. Total global investments in health R&D (both public and private sector) in 2009 reached US$240 billion. Of the US$214 billion invested in high-income countries, 60% of health R&D investments came from the business sector, 30% from the public sector, and about 10% from other sources (including private non-profit organisations). Only about 1% of all health R&D investments were allocated to neglected diseases in 2010. Diseases of relevance to high-income countries were investigated in clinical trials seven-to-eight-times more often than were diseases whose burden lies mainly in low-income and middle-income countries. This report confirms that substantial gaps in the global landscape of health R&D remain, especially for and in low-income and middle-income countries. Too few investments are targeted towards the health needs of these countries. Better data are needed to improve priority setting and coordination for health R&D, ultimately to ensure that resources are allocated to diseases and regions where they are needed the most. The establishment of a global observatory on health R&D, which is being discussed at WHO, could address the absence of a comprehensive and sustainable mechanism for regular global monitoring of health R&D.

The mismatch between the health research and development (R&D) that is needed and the R&D that is undertaken: an overview of the problem, the causes, and solutions

One of the most pressing global health problems is that there is a mismatch between the health research and development (R&D) that is needed and that which is undertaken. The dependence of health R&D on market incentives in the for-profit private sector and the lack of coordination by public and philanthropic funders on global R&D priorities have resulted in a global health R&D landscape that neglects certain products and populations and is characterised, more generally, by a distribution that is not 'needs-driven'. This article provides an overview of the mismatch, its causes, and solutions.