This article has Open Peer Review reports available.
Industry-sponsored clinical research outside high-income countries: an empirical analysis of registered clinical trials from 2006 to 2013
© Murthy et al. 2015
Received: 20 January 2015
Accepted: 26 May 2015
Published: 5 June 2015
Industry-sponsored clinical trials, in the past performed almost exclusively in more developed countries, now often recruit participants globally. However, recruitment from outside high-income countries may not represent the ultimate target population for the intervention. Clinical trial registries provide an opportunity to quantify and examine the type of clinical research performed in various geographic regions. We sought to characterize industry-sponsored randomized controlled trials conducted in high-income countries and to compare these trials to those performed outside high-income countries.
Clinical trial data on all industry-funded randomized controlled trials conducted between 2006 and 2014 were obtained from the registry ClinicalTrials.gov. Trials were classified according to their study sites as conducted in high or non-high income countries, and data on trial characteristics were collected.
Of 22,511 relevant trials, a total of 6,085 (27.0 %) trials included study sites outside a high-income country, and 2,045 (9.1 %) were conducted exclusively outside high-income countries. Of country groups, Central Europe had the greatest number of trials (3,127), followed by Eastern Europe (2,075). The percentage of trials with study sites outside high-income countries remained relatively constant over the study period. Studies with sites outside high-income countries tended to recruit more participants (median enrolled participants 265 vs. 71, P <0.001), to be longer (median study duration 20 vs. 13 months, P <0.05), and to study more advanced phase interventions (Phase 3 or 4 trial 58 % vs. 33 %, P <0.001).
More than a quarter of industry-sponsored trials include participants from outside high-income countries and this rate remained stable over the 7-year study period. Trials conducted outside high-income countries tend to be larger, have a longer duration, and study later phase interventions compared to studies performed exclusively in high-income countries.
Industry-sponsored clinical research has traditionally been performed in high-income countries, given the established research infrastructure and the geographic location of major pharmaceutical companies. Over recent decades, however, globalization has led to the extension of industry-sponsored clinical research outside higher income regions [1–3], with approximately one-third of large company-sponsored phase III trials being conducted exclusively outside the United States of America. Indeed, the total number of countries contributing results in major clinical trial publications between 1995 and 2005 has doubled [4, 5].
A number of factors contribute to the trend towards more international study sites. First, the global burden of disease is predominantly centred outside higher income regions, potentially accelerating trial recruitment for the large sample sizes required [6–8]. Secondly, increasingly complex regulatory environments in higher-income regions may slow down trial initiation and performance . Thirdly, trials conducted in certain non-higher income countries, such as Russia, Argentina or China, may cost half the price of trials performed in the United States or Western Europe . Finally, recognition of the growing market share of less-developed regions may provide added incentive to have drugs tested and approved in these countries .
This shift is not without controversies. Due to varying regulatory and legal environments, clinical trials performed outside high-income countries are presumed to be different in design and conduct [12, 13]. Clinical trial results from outside high-income countries may not be applicable to high-income countries due to differences in treatment effect sizes, rates of publication biases, and genetically different populations [1, 3, 12–18]. Additionally, ethical concerns about trial conduct outside higher income regions persist, including access to study interventions after trials are concluded and research misconduct [2, 5, 18].
Our aim was to describe current patterns regarding the globalization of industry-sponsored clinical trials, including the number of trials performed in different geographic regions and the collaboration between these regions. Our secondary aim was to characterize and compare trials performed in high- and non-high-income countries.
We performed a cross-sectional analysis of industry-sponsored clinical trials registered in ClinicalTrials.gov. This registry is a USA-based registry of clinical trials that represents as many as 86 % of all trial registrations . It has been used to assess various aspects of clinical research activity, including correlation with disease burden, quality of clinical trials, and publication bias [20–22].
We identified all interventional trials with any funding by industry with a start date between January 1, 2006 and February 19, 2014 (date of data download). Trials studying a drug, device, biologic or dietary supplement, and employing a randomized design were selected. Trials without information on study location were excluded. Ethical approval was not obtained, given the nature of the study.
We extracted data for each trial on study start and completion dates, allocation strategy, masking, trial phase, estimated enrolment number, major condition group, participant age eligibility, funding source, study site locations and number of sites, completion status, and posting of trial results. Information was collected on both lead and secondary funding sources. Condition groups were defined by the investigators for easily-defined conditions with a large disease burden (Additional file 1).
This categorization allows for both geographic and economic stratification, and is consistent with both World Bank income-based definitions and established clinical research infrastructure . Countries were classified based on all the study sites listed in the registry record. Trials with study sites in both income regions were included in both.
Descriptive analyses were performed quantifying study sites and trials and describing trial characteristics by region and major geographic group. Differences were compared with χ2 and Mann–Whitney tests. Time series analysis was performed with regression analysis. All statistical analyses were performed with R (R: A Language and Environment for Statistical Computing, version 3.1.1, Vienna Austria, 2014).
Clinical trial sites among industry-sponsored trials registered in ClinicalTrials.gov
Major geographic groups and country regions
Total number of trials a (N = 22,511)
Trials conducted exclusively outside high-income regions a, N (%) (N = 2,045)
Total number of study sites
Trials/10 million population a
Andean Latin America
Central Latin America
Southern Latin America
Tropical Latin America
Eastern Sub-Saharan Africa
North Africa and Middle East
Central sub-Saharan Africa
Southern sub-Saharan Africa
Western sub-Saharan Africa
High-income Asia Pacific
High-income North America
In terms of number of study sites, 23 % of all sites were outside high-income countries. Trials conducted in Asia were the most likely to recruit exclusively outside high-income countries (42.1 % of all trials with sites in Asia) followed by the Americas (19.8 %).
Characteristics of industry-sponsored clinical trials performed exclusively within one major geographic group a
Major geographic group
Americas N = 406
Middle East/Africa N = 163
Asia N = 1138
Europe (non-Western) N = 256
High-income regions N = 16,246
Median study sites, N (IQR)
Median subjects enrolled, N (IQR)
Double-blinded, N (%)
Industry as lead funder, N (%)
Phase 3 or 4, N (%)
Paediatric b N (%)
Characteristics of industry-sponsored clinical trials by study site income level
All trials N = 22,511
Trials with study sites outside high-income countries, N = 6,085
Trials with study sites exclusively in high-income countries, N = 16,426
P value c
Median study sites, N (IQR)
Median participants enrolled, N (IQR)
Double-blinded, N (%)
Industry as lead funder, N (%)
Sponsored by one of the 10 largest pharmaceutical companies a N (%)
Phase 3 or 4, N (%)
Paediatric b N (%)
Median trial length, months d
Completed, N (%) e
With results posted on ClinicalTrials.gov, N (%) f
We found that more than a quarter of trials registered in ClinicalTrials.gov are recruiting participants in non-high-income countries, with the majority of these trials enrolling in both high- and non-high-income countries. Of the non-high-income geographic groups, Europe (non-Western) and Asia have the greatest proportion of trials.
Trials performed in different regions of the world differ substantially; those conducted in non-high-income countries recruit from a greater number of study sites and study more advanced-phase interventions. Trials with sites in non-high-income countries also tend to recruit more subjects when compared to those conducted exclusively in high-income countries, indicating that subjects from non-high-income countries may contribute substantially to trial results. This is consistent with the limited prior work examining potential differences in trial characteristics conducted in high- and non-high-income countries [24–26].
There are a number of factors underlying the ongoing trend of recruiting participants from non-high-income countries. The lower cost is likely a key driver, as evidenced by the high number of sites and large trial sizes among trials conducted in non-high-income regions such as Europe (non-Western) and Asia . In addition, the ease of recruitment of treatment-naïve patients with chronic disease makes non-high-income countries appealing for subject recruitment .
Anthropological analyses of international research have described three phases, where the first is a massive influx of research infrastructure into a non-high-income region, the second an increase in the regulatory environment with more stringent oversight, and the third, a shift towards specific demands about the nature of the proposed research by local researchers and patients . It is uncertain where on this continuum research activity currently lies among the regions examined, but the relatively stable activity in the regions may indicate that they may have entered the second or third phases with greater local involvement. Prior studies documenting substantial increases in trial activity in many of these non-high-income regions up through 2005 would further support this possibility [4, 5].
A number of factors should be considered when extrapolating trial results from non-high-income clinical settings to high-income countries. For one, ethical standards differ by region, despite the existence of international frameworks, leading to potential exploitation of participants [1, 29]. Streamlining regulatory oversight across regions would allow for the maintenance of trial standards, negating the search for more lax regions in which to perform studies. In addition, prior work suggests that non-high-income countries have larger effect sizes for interventional studies, raising concerns that the populations in high-income countries may not experience the benefits predicted by premarket trials . One postulated reason for this effect size difference is the narrow targeting of treatment-naïve patients with advanced phase interventions in non-high-income countries.
One of the limitations of this study is that there is no definitive classification for high- and non-high-income countries and, while we used a widely accepted categorization scheme, some of the countries may have been classified differently using other approaches. In addition, the accuracy of the data provided in ClinicalTrials.gov relies on investigators and we were not able to verify the information. There is also missing data in the registry, although we encountered only a small proportion of missing information for the variables of interest. Finally, although ClincialTrials.gov is the largest and most comprehensive trial registry, it is possible that some trials were not registered or were registered in other, country-specific registries. However, this likely represents a very small number of trials since all pharmaceutical companies seeking Food and Drug Administration approval of a drug (which is required for marketing in the USA) must register their trials in the ClinicalTrials.gov registry.
More than a quarter of all pharmaceutical company trials recruit participants from non-high-income nations. The percentage of trials in non-high-income countries remained stable over the seven-year study period. There are a number of differences in the design and conduct of trials in high and non-high-income countries, including trials in non-high-income countries enrolling more participants and studying later phase interventions. The scientific implications of participant recruitment from these diverse geographic regions and of the differences in trial characteristics in different regions warrant further exploration.
NIH R21AG043715-01A1. Funding source provided salary support to FB and KM and had no involvement in data collection or analysis, manuscript writing, or decision to submit for publication.
- Lang T, Siribaddana S. Clinical trials have gone global: is this a good thing? PLoS Med. 2012;9(6), e1001228.View ArticlePubMedPubMed CentralGoogle Scholar
- MacMahon S, Perkovic V, Patel A. Industry-sponsored clinical trials in emerging markets: time to review the terms of engagement. JAMA. 2013;310(9):907–8.View ArticlePubMedGoogle Scholar
- Lorenzo C, Garrafa V, Solbakk JH, Vidal S. Hidden risks associated with clinical trials in developing countries. J Med Ethics. 2010;36(2):111–5.View ArticlePubMedGoogle Scholar
- Khin NA, Yang P, Hung HM, Maung UK, Chen YF, Meeker-O’Connell A, et al. Regulatory and scientific issues regarding use of foreign data in support of new drug applications in the United States: an FDA perspective. Clin Pharmacol Ther. 2013;94(2):230–42.View ArticlePubMedGoogle Scholar
- Glickman SW, McHutchison JG, Peterson ED, Cairns CB, Harrington RA, Califf RM, et al. Ethical and scientific implications of the globalization of clinical research. N Engl J Med. 2009;360(8):816–23.View ArticlePubMedGoogle Scholar
- Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2095–128.View ArticlePubMedGoogle Scholar
- Pereira TV, Horwitz RI, Ioannidis JP. Empirical evaluation of very large treatment effects of medical interventions. JAMA. 2012;308(16):1676–84.View ArticlePubMedGoogle Scholar
- Siontis GC, Ioannidis JP. Risk factors and interventions with statistically significant tiny effects. Int J Epidemiol. 2011;40(5):1292–307.View ArticlePubMedGoogle Scholar
- Yusuf S. Randomized clinical trials: slow death by a thousand unnecessary policies? CMAJ. 2004;171(8):889–92. discussion 892–883.View ArticlePubMedPubMed CentralGoogle Scholar
- Kaitin KI. The landscape for pharmaceutical innovation: drivers of cost-effective clinical research. Pharm Outsourcing. 2010;2010:3605.PubMedPubMed CentralGoogle Scholar
- Imran M, Najmi AK, Rashid MF, Tabrez S, Shah MA. Clinical research regulation in India-history, development, initiatives, challenges and controversies: Still long way to go. J Pharm Bioallied Sci. 2013;5(1):2–9.View ArticlePubMedPubMed CentralGoogle Scholar
- Smith R. Publishing research from developing countries. Stat Med. 2002;21(19):2869–77.View ArticlePubMedGoogle Scholar
- Panagiotou OA, Contopoulos-Ioannidis DG, Ioannidis JP. Comparative effect sizes in randomised trials from less developed and more developed countries: meta-epidemiological assessment. BMJ. 2013;346:f707.View ArticlePubMedPubMed CentralGoogle Scholar
- Zhang D, Freemantle N, Cheng KK. Are randomized trials conducted in China or India biased? A comparative empirical analysis. J Clin Epidemiol. 2011;64(1):90–5.View ArticlePubMedGoogle Scholar
- Vickers A, Goyal N, Harland R, Rees R. Do certain countries produce only positive results? A systematic review of controlled trials. Control Clin Trials. 1998;19(2):159–66.View ArticlePubMedGoogle Scholar
- O’Connor CM, Fiuzat M, Swedberg K, Caron M, Koch B, Carson PE, et al. Influence of global region on outcomes in heart failure beta-blocker trials. J Am Coll Cardiol. 2011;58(9):915–22.View ArticlePubMedGoogle Scholar
- Goldstein DB, Tate SK, Sisodiya SM. Pharmacogenetics goes genomic. Nat Rev Genet. 2003;4(12):937–47.View ArticlePubMedGoogle Scholar
- Ana J, Koehlmoos T, Smith R, Yan LL. Research misconduct in low- and middle-income countries. PLoS Med. 2013;10(3), e1001315.View ArticlePubMedPubMed CentralGoogle Scholar
- Viergever RF, Ghersi D. The quality of registration of clinical trials. PLoS One. 2011;6(2), e14701.View ArticlePubMedPubMed CentralGoogle Scholar
- Zarin DA, Tse T, Williams RJ, Califf RM, Ide NC. The ClinicalTrials.gov results database–update and key issues. N Engl J Med. 2011;364(9):852–60.View ArticlePubMedPubMed CentralGoogle Scholar
- Bernardez-Pereira S, Lopes RD, Carrion MJ, Santucci EV, Soares RM, de Oliveira AM, et al. Prevalence, characteristics, and predictors of early termination of cardiovascular clinical trials due to low recruitment: insights from the ClinicalTrials.gov registry. Am Heart J. 2014;168(2):213–9.View ArticlePubMedGoogle Scholar
- Bourgeois FT, Olson KL, Ioannidis JP, Mandl KD. Association between pediatric clinical trials and global burden of disease. Pediatrics. 2014;133(1):78–87.View ArticlePubMedPubMed CentralGoogle Scholar
- Global Health Data Exchange: Country Profiles http://ghdx.healthdata.org/country_profiles
- Fiuzat M, Califf RM. Conduct of clinical trials in acute heart failure: regional differences in heart failure clinical trials. Heart Fail Clin. 2011;7(4):539–44.View ArticlePubMedGoogle Scholar
- Shirotani M, Kurokawa T, Chiba K. Comparison of global versus Asian clinical trial strategies supportive of registration of drugs in Japan. J Clin Pharmacol. 2014;54(7):753–64.View ArticlePubMedGoogle Scholar
- Nair SC, Ibrahim H, Celentano DD. Clinical trials in the Middle East and North Africa (MENA) Region: grandstanding or grandeur? Contemp Clin Trials. 2013;36(2):704–10.View ArticlePubMedGoogle Scholar
- Emerging Markets Clinical Trials: Eastern Europe (PH145); Cutting Edge Information. North Carolina; 2010. https://www.cuttingedgeinfo.com/research/clinical-development/central-eastern-europe-trials/. Accessed June 2, 2015.
- Petryna A. When experiments travel: clinical trials and the global search for human subjects: Princeton university press. Princeton, NJ: Princeton University Press; 2009.View ArticleGoogle Scholar
- ICH – Harmonization for Better Health. International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use. Efficacy guidelines. http://www.ich.org/products/guidelines/efficacy/article/efficacy-guidelines.html. Accessed June 2, 2015.
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.