The Integration of Clinical Trials With the Practice of Medicine
Authors: Angus Derek C. , Huang Alison J. , Lewis Roger J. , Abernethy Amy P. , Califf Robert M. , Landray Martin , Kass Nancy , Bibbins-Domingo Kirsten ,   JAMA Summit on Clinical Trials Participants, Abbasi Ali B , Abebe Kaleab Z , Abernethy Amy P , Adam Stacey J. , Angus Derek C , Ard Jamy , Berkwits Michael , Bender Ignacio Rachel A , Berry Scott M , Bhatt Deepak L. , Bibbins-Domingo Kirsten , Bonow Robert O. , Bonten Marc , Brangman Sharon A. , Brownstein John , Buntin Melinda J. B. , Butte Atul J , Califf Robert M. , Campbell Marion K , Cappola Anne R. , Chiang Anne C , Cook Deborah , Cummings Steven R , Curfman Gregory , Esserman Laura J , Fleisher Lee A , Franklin Joseph B , Gonzalez Ralph , Grossman Cynthia I , Haddad Tufia C. , Herbst Roy S. , Hernandez Adrian F. , Holder Diane P , Horn Leora , Huang Grant D. , Huang Alison , Kass Nancy , Khera Rohan , Koroshetz Walter J. , Krumholz Harlan M. , Landray Martin , Lewis Roger J. , Lieu Tracy A , Malani Preeti N. , Martin Christa Lese , McClellan Mark , McDermott Mary M. , Morain Stephanie R. , Murphy Susan A , Nicholls Stuart G , Nicholls Stephen J , O'Dwyer Peter J. , Patel Bhakti K , Peterson Eric , Prindiville Sheila A. , Ross Joseph S. , Rowan Kathryn M , Rubenfeld Gordon , Seymour Christopher W. , Taylor Rod S , Waldstreicher Joanne , Wang Tracy Y. 
Published: June 2024

Importance

Optimal health care delivery, both now and in the future, requires a continuous loop of knowledge generation, dissemination, and uptake on how best to provide care, not just determining what interventions work but also how best to ensure they are provided to those who need them. The randomized clinical trial (RCT) is the most rigorous instrument to determine what works in health care. However, major issues with both the clinical trials enterprise and the lack of integration of clinical trials with health care delivery compromise medicine’s ability to best serve society.

Observations

In most resource-rich countries, the clinical trials and health care delivery enterprises function as separate entities, with siloed goals, infrastructure, and incentives. Consequently, RCTs are often poorly relevant and responsive to the needs of patients and those responsible for care delivery. At the same time, health care delivery systems are often disengaged from clinical trials and fail to rapidly incorporate knowledge generated from RCTs into practice. Though longstanding, these issues are more pressing given the lessons learned from the COVID-19 pandemic, heightened awareness of the disproportionate impact of poor access to optimal care on vulnerable populations, and the unprecedented opportunity for improvement offered by the digital revolution in health care. Four major areas must be improved. First, especially in the US, greater clarity is required to ensure appropriate regulation and oversight of implementation science, quality improvement, embedded clinical trials, and learning health systems. Second, greater adoption is required of study designs that improve statistical and logistical efficiency and lower the burden on participants and clinicians, allowing trials to be smarter, safer, and faster. Third, RCTs could be considerably more responsive and efficient if they were better integrated with electronic health records. However, this advance first requires greater adoption of standards and processes designed to ensure health data are adequately reliable and accurate and capable of being transferred responsibly and efficiently across platforms and organizations. Fourth, tackling the problems described above requires alignment of stakeholders in the clinical trials and health care delivery enterprises through financial and nonfinancial incentives, which could be enabled by new legislation. Solutions exist for each of these problems, and there are examples of success for each, but there is a failure to implement at adequate scale.

Conclusions and Relevance

The gulf between current care and that which could be delivered has arguably never been wider. A key contributor is that the 2 limbs of knowledge generation and implementation—the clinical trials and health care delivery enterprises—operate as a house divided. Better integration of these 2 worlds is key to accelerated improvement in health care delivery.