Every idle site has a cost.

Here's the math on a site that enrolls a single patient. Activation runs about $40,000. Management runs about $3,000 a month. Over a 30-month study, that one patient costs $130,000, according to Phesi's analysis of cancer trials. At the best-performing sites in the same analysis, the cost per patient was closer to $14,000.

None of this is rare. Tufts found that 11 percent of sites are never activated, a share that hasn't changed in more than a decade. And every extra day costs both sides: in its 2024 analysis, Tufts put the direct cost of running a Phase III trial at about $55,716 a day and the value of a single day of delayed sales for a new drug at roughly $800,000.

Why sites go idle

Very few sites plan to underperform. Most idle sites trace back to the same handful of causes:

• Optimistic feasibility. Patient counts come from memory instead of a records search.
• No referral pipeline. The site expects patients to find it.
• Thin staffing. Coordinators are stretched across too many studies to screen consistently.
• Competing studies. Another trial at the same site is chasing the same patients.
• Slow startup. Tufts clocked the path from site identification to study start-up at 31.4 weeks, a full month longer than a decade earlier, with most of that time going to start-up work like contract and budget negotiations.

Feasibility that holds up

Good feasibility is evidence you could hand to someone else: eligible patient counts pulled from records, referral partners who agreed to participate before the site committed, coordinator hours matched to the protocol's screening load, and a candid list of competing studies. A site that can't produce that evidence is telling the sponsor something. The sponsor should listen.

The first 90 days

The weeks right after activation decide most outcomes. Sites that enroll well arrive at activation with a pre-screening list already built, referral partners already briefed, and a target date for the first patient. They review the screening log every week and raise their hand early when candidates aren't converting.

Existing relationships help more than people expect. In the same Tufts research, cycle times ran 28 percent longer at new sites than at repeat sites.

What sponsors can do

Sponsors carry most of the cost of an idle site, and they have more tools than they use. Select sites on their record rather than their promises, meaning enrollment by past study rather than a lifetime total. Ask for records-based patient counts and referral commitments in writing. Agree at activation on an early-warning point, like a date by which the first patients should be screened, and on what happens if it passes.

Help the sites that are close. A coordinator or a referral introduction can turn a slow site around faster than a replacement can be activated. And close the sites that won't enroll before they run up another year of management fees.

Saying no protects the site

For site leaders, the lesson cuts both ways. Taking a study you can't enroll costs the sponsor money and costs your site its reputation. Turning down the wrong study keeps your capacity, and your credibility, for the right one.