Keys to success in Phase IV studies

In clinical research, a Phase IV study, also known as a post-marketing surveillance study or a post-approval study, is conducted after a medication or treatment has been approved and made available to the general population. These trials have various aims to gather for example additional information about the drug’s long-term safety, efficacy, and optimal use in a larger and more diverse patient population than was studied during the earlier phases of development (Phases I-III).

Phase IV studies are often designed to monitor the long-term effects in real-world conditions, and assess its effectiveness compared to alternative treatments or in specific patient subgroups. These studies often involve longer durations than earlier phases and should be very similar to “normal life” setting. Phase IV may include various study designs, including randomized controlled trials, observational studies, low intervention studies or registry-based studies. It is well known in the industry that these studies can be challenging from a reporting perspective and from a data management perspective with missing data.

This white paper explores the challenges of running a Phase IV study and proposes strategies to overcome them. 

What separates Phase IV studies from traditional clinical trials, are that the drugs or devises have market approval, the decision to participate in the study being separated from the decision on treatment of the patient, and consent often only relating to collection of data. One of the first things you need to do when planning a Phase IV study is to make sure you classify it correctly based on the purpose of the project and the way it will be conducted, since regulations vary based on a number of factors including how data is collected and what countries that are involved.

Phase IV studies often involve a large number of participants spread across multiple sites and healthcare settings. The collection and integration of data from diverse sources, such as electronic health records, patient-reported outcomes, and registries, can be complex and time-consuming. Data entry errors, missing data, and variations in data quality across sites can pose challenges. In addition, factors such as patient compliance, long term-follow up, healthcare provider variability and differences in clinical practice across sites, can introduce biases that need to be carefully considered and addressed in the study design and analysis.

For any clinical study, collection, management, analysis and reporting of data is an integral part of the process. For post marketing studies we see that there is a huge benefit to use a state-of-the-art Electronic Data Capture (EDC) system integrated with other e-solutions that can address many of the challenges mentioned above. It is also important that the system is flexible enough to manage differences in clinical practice between sites.

In post marketing studies sites may have limited experience in using EDC systems. It is therefore important to use a system that is intuitive, easy to use and that does not require extensive training. A powerful and yet user-friendly EDC system is essential for the site staff because their time to enter data in the eCRF is very limited. Automated checks and alerts are helpful in achieving collection of correct and complete data as early as possible.

Ensuring data quality and accuracy is crucial for the reliability of study findings. Designing a user friendly eCRF with only the must-have data elements contributes to correct data capture. By making the data capture intuitive for the sites, with efficient page dynamics, use of drop-down menus and radio button options, as well as easy to understand query text, sites will have a higher chance in entering data correct the first time. Built-in edit checks will discover the entry of incorrect data in real time and also remind sites about missing data.

With a well design eCRF, that also includes automatic data reports, it is easy to identify issues, trends in data and do comparisons between sites. Reports for recruitment, dropout rate, screen failure rate, data review status, missing data, queries, pending forms, data entry cycle times, medical coding, key risk indicators are all valuable tools for efficient data monitoring processes.

With data coming from a variety of electronic sources, it is an advantage that this data can be integrated with the EDC system in a seamless manner either through an API or sFTP solution. By setting this up correctly data is integrated automatically in the clinical database in real time or at pre-defined time points, with minimal involvement from sites or data managers.

Patient questionnaires or clinical outcomes assessments are commonly used in Phase IV studies. It is an advantage that patients can answer these forms directly on their own devices (mobile phones or tablets), with direct integration in the clinical database. This is to avoid time-consuming entry of data by sites into the EDC system from a paper source.

Enrolling a large number of participants from diverse backgrounds can be challenging due to limited patient awareness or motivation to participate. By using a set of tools for digital and web-based advertisement and pre-screening in combination with traditional enrolment by participating sites, you can significantly increase enrolment speed and completion. Additionally, maintaining participant retention over an extended period can be difficult, as individuals may discontinue their involvement due to various reasons. This can also be managed by the use of automated reminders and notifications to participants, as well as the use of other motivational activities.

It can also be very valuable to consider a hybrid approach for late phase studies (as well as clinical trials). In a hybrid study some activities such as consent procedures and follow-up visits are performed remotely or digitally via secure video links. Allowing activities such as laboratory sampling to be performed at a satellite site closer to participants can also increase willingness to participate and stay in a study. With these types of solutions, you increase the possibilities for patients living far away from larger research sites to participate in clinical research and you can reduce the need for long distance travel.

Some of the main statistical challenges in Phase IV studies are bias due to “self-selection” of study participants and loss to follow-up in long-term studies, high numbers of confounding factors due to the real-world context, difficulties to establish causality between treatments and outcomes and difficulties to obtain a large enough and representative sample size. The involvement of highly skilled and experienced biostatisticians during the design of the study in order to identify and address these issues is important. However, advanced and innovative statistical methods alone cannot ensure a successful Phase IV study but needs to go hand in hand with methods assuring high data quality and completeness, seamless data integration and methods to lower the burden on patients and clinics.

In conclusion, running a Phase IV study poses unique challenges from both an operational and a data perspective. Addressing these challenges requires innovative solutions, robust data collection, integration, and quality control processes. By recognizing and proactively addressing these challenges, researchers and sponsors companies can enhance the reliability and utility of Phase IV study data, facilitating improved insights into the real-world safety and effectiveness of medical products.

LINK Medical has performed over 130 post marketing studies, both non-interventional and interventional studies. Contact us to learn how we can support your next study.
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