The past few years have seen an increasing number of initiatives aimed at integrating information generated outside of confirmatory randomised clinical trials (RCTs) into drug development. However, data generated non-concurrently and through observational studies can provide results that are difficult to compare with randomised trial data. Moreover, the scientific questions these data can serve to answer often remain vague. Our starting point is to use clearly defined objectives for evidence generation, which are formulated towards early discussion with health technology assessment (HTA) bodies and are additional to regulatory requirements for authorisation of a new treatment. We propose FACTIVE (Flexible Augmented Clinical Trial for Improved eVidencE generation), a new class of study designs enabling flexible augmentation of confirmatory randomised controlled trials with concurrent and close-to-real-world elements. These enabling designs facilitate estimation of certain treatment effects in the confirmatory part and other, complementary treatment effects in a concurrent real-world part. Each stakeholder should use the evidence that is relevant within their own decision-making framework. High quality data are generated under one single protocol and the use of randomisation ensures rigorous statistical inference and interpretation within and between the different parts of the experiment. Evidence for the decision-making of HTA bodies could be available earlier than is currently the case.
