Non-commercial vs. commercial clinical trials: a retrospective study of the applications submitted to a research ethics committee

There are many difficulties in undertaking independent clinical research without support from the pharmaceutical industry. In this retrospective observational study, some design characteristics, the clinical trial public register and the publication rate of noncommercial clinical trials were compared to those of commercial clinical trials. A total of 809 applications of drug-evaluation clinical trials were submitted from May 2004 to May 2009 to the research ethics committee of a tertiary hospital, and 16.3% of trials were noncommercial. They were mainly phase IV, multicentre national, and unmasked controlled trials, compared to the commercial trials that were mainly phase II or III, multicentre international, and double-blind masked trials. The commercial trials were registered and published more often than noncommercial trials. More funding for noncommercial research is still needed. The results of the research, commercial or noncommercial, should be disseminated in order not to compromise either its scientific or its social value.

Private manufacturers' thresholds to invest in comparative effectiveness trials

The recent rush of enthusiasm for public investment in comparative effectiveness research (CER) in the US has focussed attention on these public investments. However, little attention has been given to how changing public investment in CER may affect private manufacturers' incentives for CER, which has long been a major source of CER. In this work, based on a simple revenue maximizing economic framework, we generate predictions on thresholds to invest in CER for a private manufacturer that compares its own product to a competitor's product in head-to-head trials. Our analysis shows that private incentives to invest in CER are determined by how the results of CER may affect the price and quantity of the product sold and the duration over which resulting changes in revenue would accrue, given the time required to complete CER and the time from the completion of CER to the time of patent expiration. We highlight the result that private incentives may often be less than public incentives to invest in CER and may even be negative if the likelihood of adverse findings is sufficient. We find that these incentives imply a number of predictions about patterns of CER and how they will be affected by changes in public financing of CER and CER methods. For example, these incentives imply that incumbent patent holders may be less likely to invest in CER than entrants and that public investments in CER may crowd out similar private investments. In contrast, newer designs and methods for CER, such as Bayesian adaptive trials, which can reduce ex post risk of unfavourable results and shorten the time for the production of CER, may increase the expected benefits of CER and may tend to increase private investment in CER as long as the costs of such innovative designs are not excessive. Bayesian approaches to design also naturally highlight the dynamic aspects of CER, allowing less expensive initial studies to guide decisions about future investments and thereby encouraging greater initial investments in CER. However, whether the potential effects we highlight of public funding of CER and of Bayesian approaches to trial design actually produce changes in private investment in CER remains an empirical question.

Rotavirus vaccine RIX4414 (Rotarix™): a pharmacoeconomic review of its use in the prevention of rotavirus gastroenteritis in developing countries

This article provides an overview of the clinical profile of rotavirus vaccine RIX4414 (Rotarix™) in the prevention of rotavirus gastroenteritis (RVGE) in developing countries, followed by a comprehensive review of pharmacoeconomic analyses with the vaccine in low- and middle-income countries. RVGE is associated with significant morbidity and mortality among children <5 years of age in developing countries. The protective efficacy of a two-dose oral series of rotavirus vaccine RIX4414 has been demonstrated in several well designed clinical trials conducted in developing countries, and the 'real-world' effectiveness of the vaccine has also been shown in naturalistic and case-control trials after the introduction of universal vaccination programmes with RIX4414 in Latin American countries. The WHO recommends universal rotavirus vaccination programmes for all countries. Numerous modelled cost-effectiveness analyses have been conducted with rotavirus vaccine RIX4414 across a wide range of low- and middle-income countries. Although data sources and assumptions varied across studies, results of the analyses consistently showed that the introduction of the vaccine as part of a national vaccination programme would be very (or highly) cost effective compared with no rotavirus vaccination programme, according to widely used cost-effectiveness thresholds for developing countries. Vaccine price was not known at the time the analyses were conducted and had to be estimated. In sensitivity analyses, rotavirus vaccine RIX4414 generally remained cost effective at the highest of a range of possible vaccine prices considered. Despite these favourable results, decisions regarding the implementation of universal vaccination programmes with RIX4414 may also be contingent on budgetary and other factors, underscoring the importance of subsidized vaccination programmes for poor countries through the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunization).

Ethical, social and legal implications of pharmacogenomics: a critical review

OBJECTIVE

My aim was to examine the ethical, social and legal implications of pharmacogenomics.

METHODS

I performed a critical review of the literature. The primary focal point is the bioethical principle discussed. The second outcome measure is the perspective of the discussion.

RESULTS

This review documents that the pharmacogenomics issues of concern are comparable to issues concerning other genetic developments in general. However, two main issues are particular to the case of pharmacogenomics. Firstly, this review reveals that society, industry, groups and individuals appreciate the prospect of pharmacogenomics very differently. Secondly, there is a lack of research into the post-marketing implications of pharmacogenomics.

CONCLUSION

An extensive focus on the ethical, social and legal implications of pharmacogenomics, in terms of both pre- as well as post-marketing issues, is essential. Also, a multidisciplinary approach which includes individual and group opinions in an upfront manner in the research and development process is essential. Otherwise, there is a substantial risk that the positive prospects of pharmacogenomics will not survive due to fear and a lack of acceptance and understanding on the part of the general public.

An illustration of the modelling of cost and efficacy data from a clinical trial

Health care providers, purchasers and policy makers need to make informed decisions regarding the provision of cost-effective care. When a new health care intervention is to be compared with the current standard, an economic evaluation alongside an evaluation of health benefits provides useful information for the decision making process. We consider the information on cost-effectiveness which arises from an individual clinical trial comparing the two interventions. Recent methods for conducting a cost-effectiveness analysis for a clinical trial have focused on the net benefit parameter. The net benefit parameter, a function of costs and health benefits, is positive if the new intervention is cost-effective compared with the standard. In this paper we describe frequentist and Bayesian approaches to cost-effectiveness analysis which have been suggested in the literature and apply them to data from a clinical trial comparing laparoscopic surgery with open mesh surgery for the repair of inguinal hernias. We extend the Bayesian model to allow the total cost to be divided into a number of different components. The advantages and disadvantages of the different approaches are discussed. In January 2001, NICE issued guidance on the type of surgery to be used for inguinal hernia repair. We discuss our example in the light of this information.

Ethical assessment of industry-sponsored clinical trials: a case analysis

The rapid growth of clinical trials sponsored by the pharmaceutical industry and conducted by community physicians raises concerns about the scientific quality of this research and the adequacy of protections for research participants. In this article, we present an in-depth ethical analysis of a recent industry-sponsored placebo-controlled study for treatment of asthma. The ethical analysis uses a proposed ethical framework for evaluating clinical research focusing on seven ethical requirements: (1) scientific value, (2) scientific validity, (3) fair subject selection, (4) favorable risk/benefit ratio, (5) independent review, (6) informed consent, and (7) respect for enrolled subjects.

[Cost effective planning of controlled trials with diagnostic instruments of limited reproducibility]

This paper proposes a simple approach for sample size prediction in controlled diagnostic or clinical trials for group comparison when the diagnostic (imaging) instrument under consideration shows limited reliability and thus calls for taking replicate measurements on each study subject. Using a specified cost function for the overall trial, a cost optimum replication number per subject is predicted, resulting in a cost-optimum predicted group size. This approach results in remarkable cost-effectiveness, as single assessment costs based on the imaging method under consideration only present a small fraction of the overall costs of preparing study subjects for a series of measurement replications by, for example, injection of nuclear or contrast agents.

Trials in developing countries

Good clinical trials can be carried out in the developing countries but ethical issues concerning the trials are frequently brought up for international debate. The concern has its own merit but can be amended if investigators (local and international) pay serious attention to these criticisms and work out the way that will most benefit the trial participants. Although scientific progress is important, it must come after the rights, the safety and the benefit of the patients. Frequently, the ethical standard is delicately balanced, depending on who looks at it and from what angles they look. Critics, investigators, volunteers, sponsors and regulatory agencies have their own mandates, expectations and limitations, and thus they need to keep an open line of communication in order to benefit all parties involved.

Economic analysis alongside clinical trials: problems and potential

Controlled clinical trials are recognized as the best source of data on the efficacy of health care interventions. Because economic evaluation is dependent on the quality of the underlying medical evidence, clinical trials have increasingly been viewed as the natural vehicle for economic analysis. However, the closer integration of economic and clinical research raises many methodological issues. This paper discusses these issues in trial design, collection of resource use and outcome data, and the interpretation of results. Suggestions are made for resolving the major problems.

OMERACT II: the biologics perspective

The development of biologic agents for the treatment of rheumatic diseases will necessitate inclusion of pharmacoeconomic analyses in the phase III trials. These products are expensive to manufacture, administer, and monitor. Typically, they require parenteral administration and regular monitoring. Often the duration of benefit is brief; although they may effectively serve as "induction therapy." For example, we have a "wonderful new biologic agent," judged effective by the ACR preliminary index for improvement, which after 2 treatment courses at +1500 (US) each, offers a year of "clinically meaningful" improvement with an acceptable safety profile in most patients. How will we convince our regulatory authorities and health services agencies that it should be approved and added to our formularies? It will be necessary to prospectively collect information about its costs (both direct and indirect) and the costs of alternative treatments. In the multicenter clinical trials for approval, patients' opinions about their health status, quality of life, and the treatment itself must be sought. In addition to a disease specific measure of function/disability, a generic measure of health status/quality of life should be included. Use of a health utilities instrument will allow comparison of different therapeutic interventions. The promise of specifically targeting disregulated immune responses without altering underlying normal immune function makes biologic agents uniquely attractive for use in an early disease population. It will therefore be important to identify those indirect costs saved or gained by maintaining function and work capacity, as well as the direct (and indirect) costs incurred by treatment associated toxicities.(ABSTRACT TRUNCATED AT 250 WORDS)

A simple method to measure gait for use in arthritis clinical research

This report describes and discusses a simple, inexpensive method to quantify step length, stride width, cadence (steps per minute), and velocity (centimeters per second) for use as outcome measures in arthritis clinical trials. The method involves footprint recordings taken during gait on pressure-sensitive paper. Data from 42 adults with osteoarthritis of the knee and a brief review of the literature suggest that gait measurements using this method are reliable, valid, and practical.