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Clin Trials. 2019 Mar 29:1740774519839391. doi: 10.1177/1740774519839391. [Epub ahead of print]

Globalization of clinical trials: Variation in estimated regional costs of pivotal trials, 2015-2016.

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1 Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
2 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
3 Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD, USA.
4 Institute for Safe Medication Practices, Alexandria, VA, USA.
5 Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA.



Despite the increasing globalization of clinical trials, little is known regarding how the trial site costs vary around the world. We quantified the geographical distribution and regional cost differences for the clinical trials that established the benefits for new therapeutic drugs approved by the US Food and Drug Administration in 2015 and 2016.


We included all pivotal clinical trials for 59 new molecular entities approved by the US Food and Drug Administration in 2015 and 2016 that included at least one site in North America. We derived cost estimates from IQVIA's CostPro, a global clinical trial cost-estimating tool used by pharmaceutical sponsors. We assessed the patient and site allocation of these trials across eight geographic regions. To quantify the region-specific cost differences, we conducted a within-trial comparison by expressing the estimated regional costs associated with the sites in each global region as a percent of the same costs in North America. We also estimated the percentage breakdown of regional cost components (pass-through, site management, regulatory, and study conduct costs) for each trial and for all endpoints reported the median and interquartile range.


Overall, 127 pivotal clinical trials enrolled 91,415 patients from 13,264 sites. Most patients (60.3%) and sites (57.3%) were outside North America. A median of 66% of the total estimated trial costs (interquartile range: 60%-72%) were spent on regional tasks, with the largest share (53.3%) going directly to trial sites and the remainder going to other regional trial management tasks. Differences were greatest in four lower cost regions: Africa, with an estimated regional cost per site of 49% of North America (interquartile range: 44%-56%), Central Europe 50% (interquartile range: 41%-63%), Middle East 53% (interquartile range: 42%-64%) and Latin America 59% (interquartile range: 50%-70%). Overall, 90 (71%) of the 127 pivotal trials had a total of 3160 sites in these lower cost regions. In contrast, savings were more limited in Western Europe, Oceania, and Asia, where estimated regional costs were 78% of North America (interquartile range: 67%-89%). One-quarter of the trials with sites in Asia and Oceana did not achieve cost savings in those regions relative to North America.


Among this sample of pivotal trials for recently approved US Food and Drug Administration products, most patients and sites enrolled were outside of North America, with selection of regional sites having a significant impact on total trial costs.


Clinical trials; cost savings; globalization of clinical trials


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