Life Science Compliance Update

September 19, 2016

New Rule and Guidance Issued on Clinical Trials

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Clinical trials are one of the most visible components of the biomedical research field, in part due to the way they directly engage human participants. Clinical trials have done a lot of good, providing advances in diagnosis, treatment, and prevention, but there are still large challenges. As such, changes are always needed to reflect science and society’s movement to increase efficiency, accountability, and transparency in clinical research.

Health and Human Services Final Rule

In an effort to make information about clinical trials more widely available to the public, the United States Department of Health and Human Services (HHS) issued a final rule that specifies requirements for registering certain clinical trials and submitting results information to ClinicalTrials.gov. The final rule expands the legal requirements for submitting registration and results information for clinical trials that involve drug, biological, and device products regulated by the Food and Drug Administration (FDA).

The requirements found within the rule generally apply to the “responsible party,” typically the sponsor of the clinical trial or designated principal investigator. The rule lays out a process for determining who the rule applies to, and which studies are considered “applicable clinical trials.”

Requirements under the final rule apply to most interventional studies of drug, biological and device products that are regulated by the FDA. The requirements do not apply to phase 1 trials of drug and biological products, or small feasibility studies of device products. The final rule also specifies how and when information collected in a clinical trial must be submitted to ClinicalTrials.gov. It does not, however, dictate how clinical trials should be designed or conducted, or what data must be collected.

Responsible parties must register their trial within twenty-one days of enrolling the first participant. The rule includes specific data elements that are to be submitted upon registration. Additionally, if the product studied is available via expanded access (when a product is used outside of a clinical trial, before it is FDA approved), the responsible party shall submit information about how patients can get access to that product.

Results information from applicable clinical trials shall generally be submitted within one year after the trial’s primary completion date. Submission of results information may be delayed, in certain circumstances, for up to two additional years for trials of products regulated by the FDA that are unapproved, unlicensed, or uncleared.

The type of information submitted will consist of “tables of information summarizing: 1) participant flow information, 2) demographics and baseline characteristics of the enrolled participants, 3) primary and secondary outcomes, including results of any scientifically appropriate statistical tests, and 4) adverse events.” As part of adverse events information there will be a table for all-cause mortality. The information will be submitted in aggregate, with no personally identifiable information. The rule requires responsible parties to update the information annually.

The final rule will be effective January 18, 2017. As of that date, ClinicalTrials.gov will allow responsible parties to comply with the rule; there is a ninety-day grace period for responsible parties to come into compliance with the requirements of the rule.

National Institutes of Health Policy Guidance

The National Institutes of Health (NIH) is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is the largest public funder of clinical trials in the United States. With such investment comes great responsibility. As such, NIH must work to ensure supported trials: investigate a mission-relevant question of high priority, do not duplicate previously conducted trials that do not need replication, and have the highest likelihood to advance knowledge and improve health.

NIH has launched a new effort to improve the quality and efficiency of clinical trials. These initiatives will reengineer the process by which clinical investigators develop ideas for new trials, how NIH reviews and selects clinical trials for support and oversees the progress of the research, and how results and aggregate data are shared broadly and rapidly.  

As part of the aforementioned initiatives, NIH issued a policy on the same day as the HHS final rule, in an attempt to promote broad and responsible dissemination of information from NIH-funded clinical trials through ClinicalTrials.gov. The policy establishes the expectation that investigators that conduct clinical trials funded at all by NIH will ensure that the trials are properly registered and that results information of the trials are submitted to ClinicalTrials.gov.

The policy, similar to the rule, requires applicable clinical trials to be registered in ClinicalTrials.gov no later than twenty-one calendar days after the enrollment of the first participant.

Applicants and offerors seeking NIH funding will be required to submit a plan for the dissemination of NIH-funded clinical trial information that will address how expectations contained within the policy will be met.

The new NIH policy applies to all NIH-funded trials, including phase 1 clinical trials of FDA-regulated products and small feasibility device trials, as well as products that are not regulated by the FDA, such as behavioral interventions.

The policy will take effect January 18, 2017. Failure to comply with the terms and conditions of the policy may result in enforcement actions, including termination.

FDA and NIH Comments

“When people participate in clinical trials, they are volunteering to create generalizable knowledge to help others in the future and we want their participation honored by ensuring that the existence of trials and their results are available to all patients and their healthcare providers, as well as researchers,” said FDA Commissioner Robert M. Califf, M.D. “The FDA will help ensure compliance with these new requirements so that patients and providers can have confidence in and access to significantly more clinical trial information, and researchers can improve clinical trial focus and design.”

“Access to more information about clinical trials is good for patients, the public and science,” said NIH Director Francis S. Collins, M.D., Ph.D. “The final rule and NIH policy we have issued today will help maximize the value of clinical trials, whether publicly or privately supported, and help us honor our commitments to trial participants, who do so much to help society advance knowledge and improve health.”

A summary table of both the final rule and new guidelines can be found here.

August 01, 2016

PhRMA and BIO Release Drug Maker Communication Guidelines

Guideline-review

On Wednesday, July 27, 2016, the Pharmaceutical Research and Manufacturers of America (PhRMA) and the Biotechnology Innovation Organization (BIO) released guidelines for drug makers’ communications with other health care professionals about their products.

The guidelines encompassed nine principles aimed at improving relationships between biopharmaceutical companies and other players in the health care industry, calling on the Food and Drug Administration (FDA) to clarify what information biopharmaceutical companies can share in addition to approved labels. The principles focused on three main areas, commitment to: science-based communications, providing appropriate context about data, and accurately representing data.

According to the guidelines,

"To exercise sound medical judgment in treating patients, health care professionals must understand the full range of treatment options, including both established and emerging information about available medications. Biopharmaceutical companies are uniquely positioned to help health care professionals achieve the best outcomes for patients, because companies can provide timely, accurate, and comprehensive information about both approved and unapproved uses of the medications they research, develop, and bring to patients. PhRMA, BIO, and their members believe that the availability of a wider range of truthful and non-misleading information can help health care professionals and payers make better informed medical decisions for their patients, which in turn will benefit patients."

The principles are as follows:

  1. Commitment to Accurate, Science-Based Communications
  2. FDA-Approved Labeling is a Primary Source in Sharing Information with Health Care Professionals About Medicines
  3. Companies Should Provide Scientific Substantiation if Shared Information is Not Contained in FDA-Approved Labeling
  4. Additional Science-based Information from Sources Other Than FDA-Approved Labeling Helps Health Care Professionals and Payers Make Informed Decisions for Patients
  5. Communications Should Be Tailored to the Sophistication of the Intended Audience
  6. Science-based Information About Alternative Uses of Medicines Can Improve Health Care Decision-Making
  7. Communicating with Payers About New Medicines and New Uses of Approved Medicines Facilitates Patient Access Upon Approval
  8. Real-World Evidence Based on Patient Experience and Pharmacoeconomic Information Can Improve Understanding of Health Outcomes and Costs
  9. Commitment to Share Information Published in Scientific or Medical Journals

The principles report from PhRMA and BIO goes on to illuminate how the responsible sharing of information, including the following categories, can improve patient care and the efficiency of the health care system:

  • Data from randomized, controlled clinical trials that evaluate pre-specified endpoints under a clearly defined analysis plan.
  • Post hoc analyses, including sub-population data. Randomized controlled clinical trials and observational studies often collect information on the safety and effectiveness of medicines in subpopulations, including specific gender and ethnic cohorts. If the trial has met its primary endpoint, subpopulation information may help health care professionals develop treatment strategies based on more precise safety and efficacy data for a particular cohort of patients.
  • Observational data and real world evidence, which can help clinicians understand how medicines perform across a diverse patient population outside of controlled trials. Such data may reflect prescribing patterns in different clinical practice settings, alternative doses, and differing durations of treatment, as well as comparisons between two or more therapies.
  • Pharmacoeconomic information.

Insurers and drug companies agree that further dialogue between them could help address the high costs of specialty drugs, but the current limited safe harbors are preventing those discussions happening. Perhaps these principles will help to push these communications into the realm of reality.

November 26, 2012

Clinical Practice Guidelines and the IOM Recommendations: Not There Yet

We there yet
Clinical practice guidelines have significantly grown over the last few decades, and more than 2,500 now can be found in the archives of the Agency for Healthcare Research and Quality’s (AHRQ) National Guideline Clearinghouse.  “However, concerns have been raised about the reliability of many of these guidelines and the processes involved in their development. 

To address these concerns, the Institute of Medicine (IOM) issued a new set of standards for clinical practice guidelines in March 2011 intended to enhance the quality of guidelines being produced.  In promulgating these standards, IOM focused on eight areas: 

1.    Establishing transparency

2.    Management of conflict of interest (COI)

3.    Guideline development group composition

4.    Clinical practice guideline–systematic review intersection

5.    Establishing evidence foundations for and rating strength of recommendations

6.    Articulation of recommendations

7.    External review; and

8.    Updating

Despite these new standards, a recent study published in the Archives of Internal Medicine, noted that no systematic review of adherence to such standards had been undertaken since one published over a decade ago.  As a result, two reviewers independently screened 130 guidelines selected at random from the National Guideline Clearinghouse (NGC) website for compliance with 18 of 25 IOM standards. 

The study found that “Clinical practice guidelines are falling far short of their mandate from the Institute of Medicine (IOM) that they be transparent and objective, as well as untainted by conflicts of interest, researchers reported,” reported MedPage Today.   

Specifically, they identified inadequate information on conflicts of interest, which was provided for committee members in less than half of guidelines examined.  Moreover, of those guidelines including such information, COIs were present in over two-thirds of committee chairpersons (71.4%) and 90.5% of co-chairpersons.  Guidelines from non-U.S. groups and medical specialty societies were the most unlikely to include this information. 

The median number of IOM standards met by a random sample of 114 sets of guidelines was eight out of 18 (44.4%), and fewer than half of the guidelines adhered to at least 50% of the standards, according to Philip A. Mackowiak, MD, of the University of Maryland in Baltimore, and colleagues.   

“Subspecialty societies were the worst in this regard, with barely a third of their guidelines satisfying more than 50% of the IOM standards surveyed.”  The noted the failure of guidelines from specialty societies to provide conflict-of-interest information, the investigators noted.

“Less than a third of guidelines prepared under the aegis of subspecialty organizations -- whose recommendations carry added weight because of their special expertise and whose members stand to profit directly from such recommendations -- included information on [conflicts of interest],” the researchers argued. 

“Everybody everywhere is developing guidelines and there is no real quality control,” Dr. Mackowiak, told Reuters.  “There is no good oversight of who actually develops the guidelines or what criteria need to be met in order for them to be published.” 

Other important shortcomings were a lack of information on the process by which committee members are chosen, and non-inclusion of patient representatives or information scientists.  “Of the specific areas in which clinical practice guidelines need to be improved, none is more pressing than that having to do with the composition of committees developing the guidelines,” the researchers stated. 

In addition, benefits of treatment were more often emphasized than potential harms, and were only presented as generalizations.  A further shortcoming was that differences of opinion on the published evidence were seldom presented. "Guidelines were nearly always written in such a way as to suggest that recommendations were unanimously supported by committee members," the researchers noted. 

A final concern was the age of many guidelines.  Some authors have suggested that guidelines should be updated every 5 years, yet fewer than half of those included in this review had been updated. 

One area in which the guidelines appeared more satisfactory was in gathering and organizing evidence, although abstracts and publications in languages other than English were rarely included. 

The researchers compared their findings with a similar report published in 1999, and concluded that “little, if any, progress has been made over the past quarter century in improving the quality of clinical practice guidelines.”  An even harsher assessment was made in an invited commentary by the author of the 1999 study, Terrence Shaneyfelt, MD, of the University of Alabama at Birmingham. 

“The same problems that have plagued guideline development continue to plague guideline development; namely, their variable and opaque development methods, their often conflicted and limited panel composition, and their lack of significant external review by stakeholders throughout the development process," Shaneyfelt stated. 

In his commentary, Shaneyfelt argued in favor of the centralization of guideline development, to avoid contradictory recommendations that can only make clinical practice more difficult.  He further stated that AHRQ should only publish guidelines that adhere to the IOM standards, but is “not optimistic.”  “I hope that efforts by the Guidelines International Network are successful, but until then, in guidelines we cannot trust,” Shaneyfelt concluded. 

The commentary and article fail to point out the value of guidelines and how their use has improved practice.   Often one gets caught in the weeds of an argument and misses the forest of good that guidelines have created.    No process will be perfect, the IOM has some very good ideas in their recommendations but finding experts who have not worked with the tools they are developing is not one of them.

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