Background
An estimated 20,000 trials are initiated internationally each year [
1] with over 500 published each month [
2]. Participants volunteer for these trials under the assumption that their efforts will contribute to the advancement of science. Accordingly, study results need to be objective, publicly available, and responsibly applied to advance knowledge and healthcare practice.
Concern about the potential impact of financial conflicts of interest (fCOI) on research conduct has led to recommendations for clinical trial practices designed to maintain an investigator's independence and to avoid the introduction of bias and suppression of results. Practices that promote the objectivity of research have been outlined in national standards for research ethics boards [
3‐
6], requirements for federally funded research [
3,
7] guidance for academic institutions [
8,
9], requirements for trial registration [
10] and for manuscripts submitted to biomedical journals [
11‐
13]. We know little about adherence to these practices in the conduct of clinical trials.
We surveyed investigators about their experiences with practices designed to ensure the objectivity of research across all stages of industry and non-industry funded trials.
Results
Of 1,109 eligible investigators at Canadian sites, 844 (76%) responded. Among responders, 76 (7%) declined participation and 36 (3%) answered only the preliminary administrative questions. 732 investigators (included response rate, 66%) were in our final analysis. Of these, 32 did not provide information related to clinical trial experience but provided responses related to personal experiences with fCOI.
Almost all of the 732 investigators held primary university appointments. 67% had over five years of trial experience, and 64% had been the overall principal investigator for at least one trial (Table
2). More than 80% of investigators had participated in multi-site trials. Approximately half (n = 406) had been investigators on trials funded by both industry and non-industry sources.
Table 2
Investigator characteristics and clinical trial experience
Primary appointment
| |
University or academic teaching hospital | 684(93) |
Non-academic community-based hospital | 27(4) |
Other (e.g. private practice, cancer centre, pharmaceutical) | 21(3) |
Type of clinical trial
| |
Non-industry trials only | 240(33) |
Industry trials only | 54(7) |
Both non-industry and industry trials | 406(55) |
None | 28(4) |
Did not answer | 4(1) |
Number of years of experience in clinical trials
| |
≤ 5 | 192(26) |
> 5 | 489(67) |
Not applicable | 28(4) |
Did not answer | 23(3) |
Most senior role in clinical trial
| |
Principal investigator for entire trial -(trial PI) | 466(64) |
Principal investigator for site, No overall PI experience- (site PI) | 177(24) |
Other (No PI or site-PI experience) | 56(8) |
Did not answer | 33(5) |
Intervention(s) studied *
| |
Drug therapy | 552(75) |
Device/equipment | 217(30) |
Diagnostic tests | 174(24) |
Surgery/procedure | 151(21) |
Education/counselling | 139(19) |
Management policy (e.g. specific thresholds for transfusion) | 89(12) |
Complementary and alternative medicine | 78(11) |
Psychotherapy | 37(5) |
Other (e.g. exercise, nutrition, radiation) | 113(15) |
Trial sites
| |
Single | 94(13) |
Multiple | 252(34) |
Both (single and multiple) | 353(48) |
Did not answer | 33(5) |
Conflict of interest exposure
| |
Any | 269(37) |
Personal only | 33(5) |
Witness of colleague | 184(25) |
Both personal and witness of colleague | 52(7) |
None | 402(55) |
Did not answer | 61(8) |
Preferred Practices
700 investigators provided data about adherence to the practices designed to promote the objectivity of research in their non-industry (n = 646 investigators) and industry (n = 460) funded trials (Table
3).
Table 3
Adherence to the 11 preferred practices stratified by trial stage and funding
Signed contracts reviewed by institution
‡
| | | | |
Signed contracts | 458 | 262 | 376 | |
No trials | 13(3) | 10(4) | 10(3) | |
Some trials | 39(9) | 21(8) | 18(5) | |
All trials §
| 374(82) | 191(73) | 330(88) | Similar |
Not sure | 22(5) | 32(12) | 12(3) | |
Did not answer | 10(2) | 8(3) | 6(2) | |
Signed contracts have restrictive confidentiality clauses
‡
| | | | |
Signed contracts | 458 | 262 | 376 | |
No trials §
| 54(12) | 48(18) | 28(7) | Similar |
Some trials | 99(22) | 35(13) | 58(15) | |
All trials | 201(44) | 77(29) | 212(56) | |
Not sure | 94(21) | 94(36) | 72(19) | |
Did not answer | 10(2) | 8(3) | 6(2) | |
Budgetary reviewed by a research ethics board or institution official
| | | | |
No trials | 39(6) | 49(8) | 22(5) | |
Some trials | 92(13) | 56(9) | 28(6) | |
All trials §
| 523(75) | 487(75) | 386(84) | Similar |
Not sure | 28(4) | 38(6) | 18(4) | |
Did not answer | 18(3) | 16(2) | 6(1) | |
Trials registered in trial registry since 2005
| | | | |
No trials | 50(7) | 56(9) | 36(8) | |
Some trials | 221(32) | 173(27) | 69(15) | |
All trials §
| 274(39) | 254(39) | 141(31) | Similar |
Not sure | 140(20) | 138(21) | 193(42) | |
Did not answer | 15(2) | 25(4) | 21(5) | |
Trial Conduct Stage
|
Funder owns study data
| | | | |
No trials §
| 258(37) | 394(61) | 52(11) | Higher in non-industry |
Some trials | 221(32) | 42(7) | 114(25) | |
All trials | 107(15) | 68(11) | 172(37) | |
Not sure | 87(12) | 119(18) | 114(25) | |
Did not answer | 27(4) | 23(3) | 8(2) | |
Investigator has access to data from all sites
| | | | |
No trials | 80(11) | 69(11) | 61(13) | |
Some trials | 191(27) | 94(15) | 108(23) | |
All trials §
| 265(38) | 306(47) | 99(22) | Higher in non-industry |
Not sure | 132(19) | 147(23) | 181(39) | |
Did not answer | 32(5) | 30(5) | 11(2) | |
Funder controls final decisions regarding: |
Study design
| | | | |
No trials §
| 247(35) | 366(57) | 78(17) | Higher in non-industry |
Some trials | 228(33) | 46(7) | 112(24) | |
All trials | 141(20) | 118(18) | 179(39) | |
Not sure | 63(9) | 98(15) | 84(18) | |
Did not answer | 21(3) | 18(3) | 7(2) | |
Data analysis
| | | | |
No trials §
| 276(39) | 397(61) | 92(20) | Higher in non-industry |
Some trials | 222(32) | 37(6) | 114(25) | |
All trials | 120(17) | 109(17) | 155(34) | |
Not sure | 61(9) | 85(13) | 92(20) | |
Did not answer | 21(3) | 18(3) | 7(2) | |
Data interpretation
| | | | |
No trials §
| 300(43) | 404(63) | 103(22) | Higher in non-industry |
Some trials | 207(30) | 36(6) | 111(24) | |
All trials | 106(15) | 106(16) | 126(27) | |
Not sure | 66(9) | 82(13) | 113(25) | |
Did not answer | 21(3) | 18(3) | 7(2) | |
Trial Dissemination Stage
|
Funder controls final decision on content of submitted manuscripts
| | | | |
No trials §
| 368(53) | 445(69) | 124(27) | Higher in non-industry |
Some trials | 168(24) | 37(6) | 100(22) | |
All trials | 49(7) | 41(6) | 70(15) | |
Not sure | 88(13) | 100(15) | 157(34) | |
Did not answer | 27(4) | 23(4) | 9(2) | |
Completed manuscripts has ghost authorship
| | | | |
No trials §
| 450(64) | 478(74) | 147(32) | Higher in non-industry |
Some trials | 100(14) | 35(5) | 75(16) | |
All trials | 5(1) | 4(1) | 8(2) | |
Not sure | 117(17) | 104(16) | 220(48) | |
Did not answer | 28(4) | 25(4) | 10(2) | |
Overall, in the trial preparation stage, 458 (65%) investigators had a signed contract for one or more trials. Of these, 374 (82%) investigators reported always having the contracts reviewed by the research ethics board (REB) or institution and 54 (12%) reported no restrictive confidentiality clauses within the contract. 523 (75%) reported always having their budgets reviewed by their REB or institution, and 274 (39%) reported always having their trials registered (since 2005). For these 4 practices, full adherence was similar between industry and non-industry trials.
In the trial conduct stage, less than half of investigators reported full adherence to preferred practices in all of their trials with regards to data ownership (37%); data access (38%); control over study design (35%); data analysis (39%); and data interpretation (43%). In the trial dissemination stage, 368 (53%) investigators reported always having ultimate control over the contents of submitted manuscripts and 450 (64%) reported an absence of ghost authorship in all their manuscripts. In addition to these reports of full adherence to preferred practice, other investigators reported following these preferred practices in some trials, but not all trials. Full adherence to preferred practices in the trial conduct and dissemination stages was generally higher for non-industry relative to industry funded trials.
We also stratified investigators according to whether they had experience in only a single funding environment or in both industry and non-industry funding environments and compared the frequency of preferred practices between industry and non-industry funded trials within these strata. We found no differences in the overall pattern of responses in either stratum. These results are not reported here but are available in Additional file
2.
Personal Experience with fCOI
Overall, 269 (37%) investigators reported having personally experienced or witnessed a situation involving fCOI (Table
4). These experiences were personal (n = 33), witnessed in a colleague (n = 184), or both (n = 52). Of 85 investigators who personally experienced a fCOI situation, the most frequent theme was related to recruitment (33%). Another theme involved study conduct (24%). 61 (72%) indicated that these fCOI experiences involved industry-funded trials.
Table 4
Thematic description of personal conflicts of interest situations
Recruitment | 28 (33) | • Pressure to recruit patients
| 31 (13) | • Investigators receive direct benefit from enrolling patients
|
Study conduct | 20 (24) | • Being asked to have a paper ghost-written
| 37 (16) | • Review focusing on trials with positive result
|
Personal financial incentives | 9 (11) | • Possible financial gain by success of a drug/study
| 56 (24) | • Equity holding in a company whose product is being investigated
|
Conflicting roles | 6 (7) | • Invented and patented devices and involved in their study
| 19 (8) | • Being the site principal investigator and the patient's physician
|
Of 236 investigators who reported witnessing a fCOI situation in a colleague's research, the most frequent theme related to personal financial incentives (24%) (Table
4). 180 (76%) of respondents indicated that the situations they witnessed were in relation to industry-funded trials.
Discussion
To our knowledge, our study is the first to obtain information directly from investigators about practices related to fCOI that may introduce bias into a trial at the preparation, conduct, and dissemination stages. Previous studies have largely relied on information obtained from indirect sources. For example, information on restrictive confidentiality clauses has come from surveys of medical school research administrators [
17] while information on investigator participation in trial design, data access, and publications has come from surveys of medical schools officials [
18]. Court documents have been the source of information for much of what we know about the practice of ghost authorship [
19‐
23]
Our findings suggest that full adherence to preferred practice was highest when these practices are required and enforced by an external agent. Specifically, three quarters of investigators reported that all of their contracts and budgets were reviewed by an REB or an institutional official. Further, these practices were equally likely to occur in industry and non-industry funded trials. The high rate of compliance may reflect the requirement of institutions to review contracts and vigilance that ethics board members apply when they review studies [
24]. Adherence to trial registration was also similar for industry and non-industry trials after 2005 (when registration became a precondition for publication in an ICMJE journal [
13]). Registration has been a legal requirement for all trials of interventions receiving regulatory approval in the United States since 2007 [
10] and has been included in the World Medical Association Declaration of Helsinki since 2008 [
25].
We found that adherence was lowest for preferred practices outlined by ICMJE regarding trial conduct and dissemination. There are a number of possible explanations for this result. First, these practices are recommended but not required by all medical journals. Second, the ICMJE recommendations generally target disclosure of information at the publication stage of the trial. Guidance introduced earlier in the process would alert investigators to preferred practices and encourage their incorporation into the study design. A fCOI Checklist [
26] aimed at prospectively identifying investigator fCOI in trials has been recently developed. To facilitate the conduct of preferred practices throughout the course of a clinical trial, this fCOI Checklist is intended to be initiated during the trial preparation stage and continues through to the trial's result dissemination stage [
26].
Our data are consistent with previous evidence that a substantial proportion of trials have ghost authorship [
19,
21,
22]. Less than a third of surveyed individuals indicated that ghost authorship was absent in all of their industry sponsored trials experience compared to more than two thirds for non-industry trials. A coordinated oversight strategy has been proposed to address this problem [
19]. Increased awareness of this issue is important so that investigators understand the potential bias introduced by ghost authors.
Our findings are robust given that our original survey was worded so that investigators responded without explicit knowledge of the preferred behaviour. Additionally, identical questions were used to capture industry and non-industry funded trial experience. Our large number of respondents and reasonable response rate indicates the willingness of investigators to discuss potentially sensitive issues concerning their experiences. Our findings also describe the experiences of individual investigators. More than a third reported having personally experienced or witnessed a situation of potential fCOI, mostly in industry-funded trials. One of the most frequently described situations related to recruitment pressures. Our study indicates the need to explore this issue further.
Limitations
First, our sample of Canadian investigators may not reflect the perspectives of investigators globally. Increasingly, clinical research sites are moving to areas such as Eastern Europe and Latin America that may have less experience with clinical trials [
27]. Second, our sample included only registered clinical trials. Since, registration has been a precondition for publication in an ICMJE journal since 2005 [
13] the trials included in our sample may have been of higher quality than trials that were not registered. Some of the trials included in our sample pre-date the mandatory registration period. Third, response bias is a concern, particularly when addressing potentially sensitive issues involving fCOI. Our guarantee of anonymity, and user-friendly questions helped to encourage disclosure of useful information. The response rate to our email survey was 76% with 66% useable responses. We have no information from non-responders and therefore are unable to describe these individuals. Further, our main study outcome was full adherence to preferred practice in all of their trials experiences within 5-years of our survey. We recognize that other surveyed investigators followed the preferred practices in some but not all trials. Finally, we surveyed investigators about their trial experience prior to 2007. Since we aimed to capture practices across all stages of clinical trial conduct and study result dissemination (average 4 to 8 years from inception to completion [
28]), we needed to allow sufficient time for publication. Our results may not fully reflect current practices but they provide a baseline from which future studies can build.
Competing interests
Joel Lexchin was retained by a law firm representing Apotex to provide expert testimony about the effects of promotion on the sales of medications. He has also been retained as an expert witness by the Canadian federal government in its defense of a law suit launched challenging the ban on direct-to-consumer advertising of prescription drugs in Canada. No conflicts reported for rest of the authors.
Authors' contributions
PAR, JH, JL, LEF, DM, MVL, JG, JM, DS, NT, AWC conceived the project; PAR, JH, JL, LEF, DM, JG, JM, DS, NT, AWC obtained the funding; PAR, MS, JH, JL, LEF, DM, MVL, JG, JM, NT, AWC participated in the design of the survey; MS, SRK were research assistants on the study and were involved in data collection; PAR, MS, JH, JL, LEF, DM, WW, SRK, MVL, AG, JM, DLS, NT, AWC participated in analyzing the research; PAR, MS, JH, JL, LEF, DM, WW, SRK, MVL, AG, JG, JM, DLS, NT, AWC helped to draft the manuscript, and approved the final manuscript
PAR is the study guarantor.