Uneasy alliance--clinical investigators and the pharmaceutical industry

Practicing research ethics: private-sector physicians & pharmaceutical clinical trials

This paper focuses on constructions of research ethics by primary care physicians in the USA as they engage in contract research for the pharmaceutical industry. Drawing first on historical studies of physicians as investigators and then on 12 months of qualitative fieldwork in the Southwestern US, this paper analyzes the shifting, contextualized ethics that shape physicians' relationships with patients/subjects and pharmaceutical companies. Just as physicians followed professional codes of ethics prior to the codification of acceptable research conduct in the 1980s, physicians today continue to develop tacit systems of research ethics. This paper argues that private-sector physicians primarily conceptualize their ethical conduct in relation to the pharmaceutical companies hiring them, not to human subjects they enroll in clinical trials. This is not to say that these physicians do not follow the formal U.S. regulation to protect human subjects, but rather that their financial relationships with the pharmaceutical industry have a greater influence on their identities as researchers and on their constructions of their ethical responsibilities.

Effects of disclosing financial interests on attitudes toward clinical research

BACKGROUND

The effects of disclosing financial interests to potential research participants are not well understood.

OBJECTIVE

To examine the effects of financial interest disclosures on potential research participants' attitudes toward clinical research.

DESIGN AND PARTICIPANTS

Computerized experiment conducted with 3,623 adults in the United States with either diabetes mellitus or asthma, grouped by lesser and greater severity. Respondents read a description of a hypothetical clinical trial relevant to their diagnosis that included a financial disclosure statement. Respondents received 1 of 5 disclosure statements.

MEASUREMENTS

Willingness to participate in the hypothetical clinical trial, relative importance of information about the financial interest, change in trust after reading the disclosure statement, surprise regarding the financial interest, and perceived effect of the financial interest on the quality of the clinical trial.

RESULTS

Willingness to participate in the hypothetical clinical trial did not differ substantially among the types of financial disclosures. Respondents viewed the disclosed information as less important than other factors in deciding to participate. Disclosures were associated with some respondents trusting the researchers less, although trust among some respondents increased. Most respondents were not surprised to learn of financial interests. Researchers owning equity were viewed as more troubling than researchers who were compensated for the costs of research through per capita payments.

CONCLUSIONS

Aside from a researcher holding an equity interest, the disclosure to potential research participants of financial interests in research, as recommended in recent policies, is unlikely to affect willingness to participate in research.

Ethics and the pharmaceutical industry

OBJECTIVE

Relationships between the pharmaceutical industry and the medical profession enhance the potential for physicians to become involved in conflicts of interest. Whether or not these rise to a level that violates standards of medical ethics depends on the degree to which they detract from the quality of health care and its cost, the objectivity of research, and the profession's integrity. This paper explores those issues from two perspectives--the micro-level of the medical profession and the macro-level of society.

CONCLUSIONS

Practices and policies that affect varied aspects of the interaction between the pharmaceutical industry and the medical profession--such as education, research and marketing--are discussed. The reader is asked to reflect on the ethics of issues raised; the author offers suggestions for mitigating conflicts of interest and, in turn, the potential for unethical medical care.

Issues that may determine the outcome of antipsychotic trials: industry sponsorship and extrapyramidal side effect

This study presents a meta-analysis of the influence of several potentially biasing factors (eg industry support, extrapyramidal side effects) on efficacy of studies comparing second-generation antipsychotic (SGA) with first-generation antipsychotic (FGA) medications. We used the dataset from our previously published meta-analysis of 124 randomized controlled trials (RCTs) comparing SGAs with FGAs, to evaluate whether certain possible biases could influence the actual outcome on the total score of the Positive and Negative Syndrome Scale (PANSS), Brief Psychiatric Rating Scale (BPRS), and Clinical Global Impressions (CGI) scores. Industry sponsorship was determined by contact with authors or publication statement. We calculated whether (1) industry sponsorship, (2) study quality, (3) extrapyramidal symptoms (EPS) properties, or (4) prophylactic antiparkinsonian medications influenced SGA vs FGA efficacy for each drug and averaged overall by two Hedges and Olkin-based meta-analyses. The analysis found that none of the factors was significantly associated with a particular outcome. While industry-sponsored articles may conclude their medication to be more favorable than that of a competitor in an RCT, we found that the observed efficacy was not influenced by sponsorship. Many attribute the finding that SGAs appears to be more efficacious than FGAs to be a result of EPS-decreasing efficacy (or its measurement). We were unable to confirm that the drug's EPS properties or antiparkinsonian management altered actual efficacy.

Farmacêutico: profissional de saúde e cidadão

O texto foi apresentado no V Congresso de Assistência Farmacêutica/Riopharma, com o objetivo de abordar aspectos importantes para a reflexão da condição do farmacêutico como profissional e como cidadão capaz de atuar em sociedade. Para tanto, o caminho selecionado foi a rememoração de alguns fundamentos que estruturam a reforma sanitária no Brasil; a pressão dos fabricantes sobre os profissionais de saúde e as agências reguladoras; a desigualdade na distribuição dos medicamentos entre os diferentes estratos sociais. Entre as propostas de mudança apontadas estão: a ampliação do papel do farmacêutico na atenção farmacoterapêutica; a proibição da propaganda de medicamentos; a avaliação global e independente da agência de regulação nacional; e a inclusão nas bases de dados nacionais de informações sobre medicamentos consumidos durante as hospitalizações.

International research and just sharing of benefits in Mexico

International research enrolling human subjects has raised an ethical concern regarding the just distribution of benefits between the countries that design the research and the host communities. Although several universal declarations have expressed this concern, a gap between theory and practice continues to exist, as well as a significant divergence between the design of the research protocol and the social context where it will be implemented. Although institutional review boards have made a valuable effort to evaluate international research, their sensitivity to the just sharing of research benefits as well as their attention to the social context must be evaluated. This article analyzes the distribution of benefits in a review of international research in Mexico and produces an ethical reflection based on the results.

Conflicts of interest between physicians and the pharmaceutical industry and special interest groups

Health care in the United States is a tangled web of competing interest groups beneath which ethical conflicts of interest flourish. Physicians, professional organizations, and academic medical centers must continually evaluate their relationships with the pharmaceutical industry as they relate to personal, professional, and institutional ethical values. This article explores the relevant pressing ethical issues and proposals for changing course and managing these potentially troublesome relationships.

News media coverage of direct-to-consumer pharmaceutical advertising: implications for countervailing powers theory

Since a 1997 regulatory shift on the part of the US Food and Drug Administration (FDA), there has been an explosion of televised direct-to-consumer (DTC) pharmaceutical advertising in the United States. The introduction and growth of this form of advertising, as well as other recent evolutions in the health care arena, have altered relationships among key countervailing powers in the health care system, suggesting the need to recast countervailing powers theory so as to account for these changes. Coming from the perspective that the news media play an important role in reflecting the balance of power among the various countervailing powers, the paper advances this theoretical framework through an empirical assessment of the relative prominence of those entities in print news media coverage of the DTC advertising phenomenon. The study finds that `corporate sellers' (pharmaceutical industry) are accorded more prominence in news coverage than are providers, consumers, corporate purchasers, or state players and that DTC critics, in particular, have minimal representation. In addition, the findings point toward two modifications for countervailing powers theory: (1) an incorporation of the role of academic/research organizations, and (2) a consideration of the universe of possibilities with respect to each of the countervailing powers.

Running an ethical trial 60 years after the Nuremberg Code

The Nuremberg Code has served as a foundation for ethical clinical research since its publication 60 years ago. This landmark document, developed in response to the horrors of human experimentation done by Nazi physicians and investigators, focused crucial attention on the fundamental rights of research participants and on the responsibilities of investigators. Although the Nuremberg Code has provided an important framework for discussions on the requirements of ethical clinical research, and has resulted in the development of other initiatives-eg, the Declaration of Helsinki and the Belmont Report-designed to ensure the rights and safety of human beings taking part in medical research, knowledge of both past events and the current complexity of research suggests further improvements are necessary in the existing approaches to human clinical research.

Perspectives of clinical research coordinators on disclosing financial conflicts of interest to potential research participants

BACKGROUND

Disclosing financial interests to potential research participants during the informed consent process is one strategy for managing conflicts of interest. Given that clinical research coordinators are typically charged with administering the informed consent process, it is critical to understand their experiences, attitudes and beliefs regarding the disclosure of financial interests in research.

PURPOSE

To understand the role of clinical research coordinators in disclosing financial interests in research, and potential barriers to such disclosures.

METHODS

We developed a survey designed to measure clinical research coordinators' awareness of financial interests in clinical research, previous experience with disclosing financial interests, comfort with answering questions about financial interests and barriers to disclosing financial interests to potential research participants. Next we conducted cognitive interviews with 10 clinical research coordinators to assess understandability and content validity and to further refine the survey. We then administered the survey to clinical research coordinators attending the 2006 Global Conference of the Association of Clinical Research Professionals.

RESULTS

Among 300 clinical research coordinators who completed the survey, there was a general awareness of financial interests in research. Forty-one percent reported disclosing such financial interests to potential research participants, and 28% reported being asked about them. Greater comfort in responding to questions about financial interests was associated with previous experience with disclosure, previous experience answering questions about financial interests, and greater length of time obtaining informed consent. Respondents indicated that there were barriers to disclosure, including lack of information (76%) and that participants would not understand disclosures (26%).

LIMITATIONS

Possible sample bias due to using a convenience sample.

CONCLUSIONS

Making information about financial interests in research readily available to clinical research coordinators, as well as providing education and training, should facilitate the disclosure of financial interests in research to potential research participants during the informed consent process.

Maintaining the trust of physicians and the public in the medical literature: report of a task force on scientific publishing of clinical trials

In 2006, the American Society of Bone and Mineral Research and the Journal of Bone and Mineral Research convened a task force to consider whether and how to change our editorial policies to assure complete and unbiased reporting of clinical trials. We invited editors of journals that publish research on osteoporosis and disorders of bone and mineral metabolism and presidents of related societies to participate. The task force was charged to consider whether journals should (1) adopt the Principles for Protecting Integrity in the Conduct and Reporting of Clinical Trials published in 2006 by the American Association of Medical Colleges (AAMC) and should (2) require authors and sponsors of industry-funded clinical trials to provide a jointly signed letter that states that the authors had full access to all the data and analyses on which the manuscript was based. The AAMC Principles recommend that multicenter trials should designate a Lead Investigator, Steering Committee, and Publication and Analysis (P&A) Committee, which should consist of a majority of academic investigators who are not sponsor employees. The P&A Committee should have the right to access any data generated during a study and to conduct its own statistical analyses. A majority of task force members voted to support the AAMC Principles, to require a letter jointly signed by academic investigators and industry sponsor stating that the authors had access to the data on which the submission was based, and to recommend adoption of these requirements to their respective societies and journals. Broad-based adoption of the AAMC Principles and requirement of a jointly signed attestation of data access by journals that publish clinical trials in diseases of bone and mineral metabolism should improve the position of academic clinical investigators in their interactions with industry and other funding sources.

Conflicts of interest in medical practice

It has become more and more apparent that some aspects of current medical practice can no longer be kept solely within the private preserve of the profession. Medical error is now treated in an open fashion because it is clear that frank debate over its incidence, causes and mechanisms are crucial to effective prevention. This has always been one of our worst kept secrets. Equally conflicts of interest [1] assume particular relevance in an occupation whose foundation values demand a robust ethical identity. This is the topic of this essay.

Conflito de interesses em pesquisa clínica

Na pesquisa clínica há um grande potencial para o conflito de interesses e, mesmo para o pesquisador, a identificação desses conflitos pode não ser muito clara. Há muitos aspectos a serem considerados, com implicações que atingem todos os agentes que participam do processo: o sujeito da pesquisa, o pesquisador, a instituição onde a pesquisa é realizada, o patrocinador, os comitês de ética, as agências reguladoras, a comunidade científica e a sociedade em geral. A conclusão é que os conflitos de interesses são generalizados e inevitáveis na vida acadêmica. O desafio não é erradicá-los, mas reconhecê-los e manejá-los adequadamente. A única prática aceitável é que sejam expostos claramente e que todas as pesquisas em seres humanos passem pelo crivo dos comitês de ética em pesquisa.

Ghost management: how much of the medical literature is shaped behind the scenes by the pharmaceutical industry?

Sismondo discusses how pharmaceutical companies and their agents shape multiple steps in the research, analysis, writing, and publication of articles.

Ethical issues concerning therapeutic studies in inflammatory bowel disease

Physicians often take on responsibilities beyond medical care regarding their patients with ulcerative colitis and Crohn's disease: they serve as the patients' advocates to nonmedical entities and individuals, including insurance companies, schools, employers, companions, and family members. These responsibilities create a more complex relationship between the patient and their IBD physician. In addition, these responsibilities may accentuate ethical issues for the physician who is also engaged in clinical treatment trials for inflammatory bowel disease (IBD). Ethical issues include therapeutic misconception, clinical equipoise, and financial and nonfinancial conflicts of interest. Physicians who refer patients with IBD to enroll in treatment trials, as well as clinician investigators who conduct studies should consider measures to clarify the separation between clinical care and participation in a therapeutic study, and to ensure the ethical treatment of patients. These precautionary measures may include payment of participants to emphasize that the research study is different from clinical care, consent by an investigator other than the treating physician, and care to disclose conflicts of interest to the patient and the medical community in presentations and publications. If the financial conflict is too great, a physician should not participate in the clinical trial.

A Turning Point for Conflicts of Interest: The Controversy Over the National Academy of Sciences' First Conflicts of Interest Disclosure Policy

Conflicts of interest policies have become a part of the fabric of the conduct of biomedical research, yet such concerns are relatively recent history. Until the 1960s, concerns about conflicts of interest were confined to scientists who served as government advisors and contractors. However, in the 1970s, as a range of environmental and consumer safety issues gained public attention, the conclusions of researchers frequently came under attack because of concerns about experts' financial ties to private industry. These debates typically focused on evaluating potential carcinogens in the environment. In response, the National Academy of Sciences (NAS) developed its first conflict of interest policy, requiring committee members to disclose any “potential sources of bias” that “others might deem prejudicial.” Scientists universally opposed the policy, however, for a range of reasons—while some argued that all experienced and knowledgeable experts were inherently conflicted, others were offended at the suggestion that any expert could be biased. Despite the controversy, the disclosure policy remained in place and became a model for subsequent professional and institutional policies in the biomedical sciences. However, although disclosure policies have become standard at academic medical centers and for publications in scientific journals, clinical researchers have continued to debate the content of these policies and the need for additional protections beyond disclosure. In the absence of a definitive standard, this historical case study can substantially inform ongoing discussion on conflicts of interest in clinical research.

Attitudes Toward Research Participation and Investigator Conflicts of Interest Among Advanced Cancer Patients Participating in Early Phase Clinical Trials

Purpose

Although both financial and intrinsic conflicts of interest can exist throughout the drug development process, little is known about how advanced cancer patients enrolled onto early phase clinical trials perceive investigator conflicts of interests.

Patients and Methods

We interviewed 102 advanced cancer patients enrolled onto phase I clinical trials using a standardized survey that addressed multiple issues related to conflicts of interest and research participation.

Results

Fifty-five percent of patients would not be concerned if physicians involved in running a clinical trial had financial conflicts of interest, whereas 65% of patients would be concerned if physicians involved in running a trial had intrinsic conflicts of interest. Most patients reported that potential conflicts of interest should be disclosed to patients on research trials (52% for financial conflicts of interest and 61% for more intrinsic conflicts of interest). Most patients would be willing to participate in trials after learning conflict of interest information (63%). Younger patients expressed more concern regarding financial conflict of interest than older patients (odds ratio, 6.22; 95% CI, 1.41 to 27.24).

Conclusion

Patients with advanced cancer are equally, if not more, concerned about traditional intrinsic conflicts of interest as compared with financial conflicts of interest. Patients generally believed that conflict of interest information should be disclosed to research participants. The fact that younger patients expressed more concern about financial conflicts of interest may have the potential to influence clinical trial participation rates. The actual impact of conflict of interest disclosure to research subjects needs to be evaluated more carefully.

An analysis of the clinical development of drugs in Norway for the years 2000 and 2004: the influence of the pharmaceutical industry

OBJECTIVE

Little has been published either concerning the total number of research projects in connection with clinical development of drugs or the number of projects financially supported by the industry.

METHODS

From the archives of the five regional Norwegian Research Ethical Committees (REC), all research projects in connection with clinical development of drugs for the years 2000 and 2004 were analysed with the intention of finding the number of projects financially supported by the industry, the type of research institution, the industrial company, the topic of the research as classified in the international Anatomic Therapeutic Classification system (ATC), the research phase and the approval status of the drug by the Norwegian Medicines Agency (NMA).

RESULTS

The total number of research projects for the clinical development of drugs for the years 2000 and 2004 was 489, and 75.7% were financially supported by the industry. More than two-thirds of the projects were done in academic institutions and about one-third were equally divided between public health hospitals and private health service/hospitals. Eight of the 88 drug companies involved were among the world's largest and supported 38% of the projects. Fifty-nine percent of all the projects were within four therapeutic groups: antineoplastic/immunomodulating agents, nervous system, cardiovascular system and alimentary tract/metabolism. The distribution of research phases was as follows: phase I 1.2%, phase II 16.4%, phase III 26.6% and phase IV 55.8%. In the phase IV drug trials, drugs had been approved for sale by the NMA.

CONCLUSIONS

The share of research projects related to the development of drugs supported by the industry is high. Research independent of the industry is of importance to avoid bias and selective publications and to prevent research as a means of marketing. Independent research should be encouraged and financially supported by sources with no connection to the drug industry.

Influence of drug company authorship and sponsorship on drug trial outcomes

Studies of drug treatments are more likely to report favourable outcomes when they are funded by the pharmaceutical industry. We compared drug trials reported in three major psychiatric journals to investigate these influences. Independent studies were more likely to report negative findings than industry-funded studies. However, the involvement of a drug company employee had a much greater effect on study outcome than financial sponsorship alone.

Is significant relevant? Validity and patient benefit of randomized controlled clinical trials on age-related macular degeneration

A large variety of new treatment options for different forms of age-related macular degeneration (ARMD) are becoming available. Not all new therapies may meet the expectations of patients and ophthalmologists. Despite the given statistical significant priority of treatment investigations, the endpoints may not be relevant to the patient's requirements. Therefore, questions inevitably arise regarding patient's benefit and the validity of the randomized controlled trials. The randomized controlled trial is regarded as the "gold standard" in terms of evaluating the effectiveness of interventions. The external validity of randomized controlled trials may be compromised, if, for example, patients assigned to the study group are unrepresentative of the reference population. This review aims to analyze problems with external validity in the randomized controlled trials on ARMD and surveys the endpoints of clinical studies with respect to the patient benefit.

Use and perceptions of clinical practice guidelines by internal medicine physicians

The authors sought to explore the use and perceptions of clinical practice guidelines among internal medicine physicians. Through a Web-based survey, 201 board-certified internal medicine physicians rated their opinions on several statements using 7-point Likert scales. Most respondents (74.7%) felt that guidelines were suitable for at least half of their patients, although a failure to take comorbid conditions into account was a frequently cited barrier. For patients with cardiovascular disease, there was no difference between individual internists' perceptions of their own compliance with guidelines and their estimates of cardiologists' compliance (P = .14). A large majority of respondents (70.7%) believed that guideline committee member participation in industry-funded research introduces bias into guideline content (median [interquartile range], 5 [4-6]). Although most respondents felt that measuring physicians against guideline-based performance measures encourages evidence-based medicine (76.5%), opinions were split as to whether this practice distracts from patient care or compromises physician autonomy.

The EU-regulation on medicinal products for paediatric use: impacts on child and adolescent psychiatry and clinical research with minors

BACKGROUND

At present the EU-regulation on medicinal products for paediatric use is in the final legislation phase. The Regulation will bring essential changes to the policy of research with minors, to funding and to regulations of drug development in Europe.

METHOD

The article analyses contents of the regulation and possible effects on research with and treatment of mentally ill minors.

RESULTS

The regulation seems to be a chance to improve pharmacological treatment for children and bring similar research conditions to Europe as they already exist in the US. Some terms of the regulation must be considered as critical due to vague definitions and ambiguously defined policies in some articles. The designated expert committee will be a powerful institution, but it remains to be seen whether this committee will act in the intended way. It is an existing and real danger that European child and adolescent psychiatry will be neglected by the new regulation, if there is no participation of scientists of this discipline in committees. The regulation makes it necessary for child and adolescent psychiatry to strengthen research in clinical trials and developmental psychopharmacology to get benefits from new legislation and improve health care for mentally ill minors.

Ethical attitudes of nurse, physician, and unaffiliated members of institutional review boards

PURPOSE

To evaluate the recommendation for adding unaffiliated members to institutional review boards (IRB) by comparing the attitudes and influence of IRB members of different backgrounds, primarily nurses, physicians, and unaffiliated members.

DESIGN

Survey.

METHOD

A closed-ended self-administered questionnaire concerning ethical issues in human subjects research was completed by 284 IRB members in a nonprobability sample of 27 IRBs in 12 U.S. states. The attitudes and influence of IRB members with different backgrounds were compared.

FINDINGS

Nurses rated most of the issues as more important than did all other members; physicians rated most of the issues as less important than did all other members; and unaffiliated IRB members rated the issues similar to the whole. Nurses and unaffiliated members were ranked the least influential IRB members, and IRB chairs and physicians were ranked the most influential.

CONCLUSIONS

The responses of the IRB members in this study indicate that adding more unaffiliated members to IRBs is unlikely to increase IRB concerns with ethical issues. Adding more nurse members to IRBs might increase IRB concerns with ethical issues if the level of influence of the nurses is increased.

Association between pharmaceutical involvement and outcomes in breast cancer clinical trials

BACKGROUND

Since 1992, pharmaceutical industry support has surpassed National Institutes of Health funding for clinical research in the United States. In this study, the authors sought to evaluate the impact of this shift in funding from public to private sponsors on the nature of published breast cancer clinical research.

METHODS

All published breast cancer clinical trials from 2003, 1998, and 1993 were reviewed from 10 select English-language medical journals to evaluate pharmaceutical involvement over time and the association between sponsorship, trial design, and results. Clinical studies that reported disease-specific outcomes from medical therapy for breast cancer were eligible for analysis. Pharmaceutical involvement was defined as reported pharmaceutical industry funding, provision of drug, and/or authorship for each publication.

RESULTS

In total, 140 eligible studies were identified, including 45 studies that were published in 1993, 39 studies that were published in 1998, and 56 studies that were published in 2003. Among those, 67 publications (48%) reported pharmaceutical industry involvement, 36 publications (26%) had at least >/=1 pharmaceutical industry author, And 100 publications (71%) were considered positive. Pharmaceutical involvement was identified in 44% of the studies published in 1993, in 38% of the studies published in 1998, and in 58% of the studies published in 2003. Pharmaceutical authorship was reported in 22% of the 1993 studies, in 21% of the 1998 studies, and in 34% of the 2003 studies. For studies that were published in 2003, those that reported pharmaceutical involvement were more likely to be positive (84% vs 54%; P = .02; Fisher exact test), to be single-arm studies (66% vs 33%; P = .03), and to evaluate metastatic disease (72% vs 46%; P = .06).

CONCLUSIONS

Pharmaceutical involvement in published clinical breast cancer research may affect study design, focus, and results. Further research is warranted, including analysis of unpublished studies, to evaluate the impact of increasing pharmaceutical industry involvement on clinical research.

A national survey of physician-industry relationships

BACKGROUND

Relationships between physicians and pharmaceutical, medical device, and other medically related industries have received considerable attention in recent years. We surveyed physicians to collect information about their financial associations with industry and the factors that predict those associations.

METHODS

We conducted a national survey of 3167 physicians in six specialties (anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics) in late 2003 and early 2004. The raw response rate for this probability sample was 52%, and the weighted response rate was 58%.

RESULTS

Most physicians (94%) reported some type of relationship with the pharmaceutical industry, and most of these relationships involved receiving food in the workplace (83%) or receiving drug samples (78%). More than one third of the respondents (35%) received reimbursement for costs associated with professional meetings or continuing medical education, and more than one quarter (28%) received payments for consulting, giving lectures, or enrolling patients in trials. Cardiologists were more than twice as likely as family practitioners to receive payments. Family practitioners met more frequently with industry representatives than did physicians in other specialties, and physicians in solo, two-person, or group practices met more frequently with industry representatives than did physicians practicing in hospitals and clinics.

CONCLUSIONS

The results of this national survey indicate that relationships between physicians and industry are common and underscore the variation among such relationships according to specialty, practice type, and professional activities.

Industry-sponsored research in developing countries

BACKGROUND

Industry has become an important source of funding for clinical research; guidelines governing the relationship between industry and medical institutions are not clear in developing countries and hence we wanted to test attitudes and practices in those countries and compare them to developed countries. We conducted a survey amongst medical practitioners in developed and Arab countries representing developing countries, in order to document their views towards industry-sponsored research and their actual practice in this regard.

METHODS

A structured questionnaire was distributed by email, mail and through personal contacts. The questionnaire included information on characteristics of the practitioners involved, their attitudes towards industry-sponsored research and their actual practices. The questionnaire was distributed to 510 medical practitioners of countries in both groups. Practitioners representing developed countries were from the United States, United Kingdom, Australia and New Zealand. Those representing developing countries included Arab countries from Asia and Africa.

RESULTS

We found that there were contrasting views and practices between the two groups although more than 80% in both groups agreed that industry-sponsored research is necessary. 69.7% of respondents in developed countries participated in industry-sponsored research while only 30.1% did so in developing countries. Guidelines governing such research were better adhered to in developed countries than in developing countries. Where there were no authors who were not part of investigators in developed countries, 16.3% of industry-sponsored research in developing countries included authors who were not part of the investigators. Research ethics committees were present in 94% and 58% of institutions in developed and developing countries respectively. Review bodies were available in 57% and 41% in developed and developing countries.

CONCLUSIONS

Industry-sponsored research is necessary; it is much more common in developed countries. Clear guidelines governing industry-sponsored research should be adopted in developing countries, including the establishment of research ethics committees and review bodies to monitor such research.

Conflict of interest in orthopaedic research. An association between findings and funding in scientific presentations

BACKGROUND

Financial conflict of interest has been associated with an increased likelihood that authors will report positive study outcomes. The purpose of this study was to investigate the association between types of declared conflict of interest and reported study outcomes in orthopaedic research.

METHODS

The abstracts of all podium presentations given at the 2001 and 2002 Annual Meetings of the American Academy of Orthopaedic Surgeons were analyzed by three orthopaedic surgeons with advanced training in clinical epidemiology. The findings reported in each abstract were graded as positive, negative, neutral, or not applicable. Self-reported conflict of interest was recorded and classified.

RESULTS

Conflicts of interest were reported in 40.8% (212) of 519 abstracts. The interobserver reliability of the grading of the study findings was acceptable (intraclass correlation coefficient, 0.725). Rates of conflict of interest related to royalties, stock options, or consultant or employee status varied significantly by subspecialty field (p < 0.001). The overall rate of positive study findings was 84.0% (436 of the 519 abstracts). Positive findings were more common in studies authored by individuals with a conflict of interest related to royalties (98.4% [sixty of sixty-one] compared with 88.0% [381 of 433] for studies authored by individuals without a conflict of interest related to royalties; relative risk = 1.1 [95% confidence interval = 1.0 to 1.1]; p = 0.02), in studies authored by individuals with a conflict of interest related to stock options (100.0% [twenty-nine of twenty-nine] compared with 84.7% [394 of 465]; relative risk = 1.2 [95% confidence interval = 1.0 to 1.3]; p = 0.04), and in studies authored by individuals with a conflict of interest related to consultant or employee status (97.8% [ninety-one of ninety-three] compared with 89.0% [357 of 401]; relative risk = 1.1 [95% confidence interval = 1.0 to 1.2]; p = 0.01). Positive findings were not more common in studies authored by individuals with a conflict of interest related to research or institutional funding (93.5% [143 of 153] compared with 91.8% [313 of 341]; relative risk = 1.0 [95% confidence interval = 0.95 to 1.5]; p = 0.65). In the multivariate analysis, the factors that remained significant predictors of positive outcomes were royalties (p = 0.002) and consultant or employee status (p = 0.038).

CONCLUSIONS

Self-reported conflicts of interest are common in orthopaedic research, particularly in the subspecialty fields of adult reconstruction of the knee, adult reconstruction of the hip, and spine. Presentations authored by individuals with a conflict of interest related to royalties, stock options, or consulting or employee status were significantly more likely to describe positive findings. While there may be distinct benefits associated with industry support of orthopaedic research, safeguards must be established to maintain public trust in the medical research establishment.

The ICMJE and URM: Providing Independent Advice for the Conduct of Biomedical Research and Publication

The International Committee of Medical Journal Editors (ICMJE) is a working group of editors of selected medical journals that meets annually. Founded in Vancouver, Canada, in 1978, it currently consists of 11 member journals and a representative of the US National Library of Medicine. The major purpose of the Committee is to address and provide guidance for the conduct and publishing of biomedical research and the ethical tenets underpinning these activities. This advice is detailed in the Committee's Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication (URM).Recently, the ICMJE has adopted an interventionist role to ensure transparency of conflict of interest revelations in the conduct and publication of industry supported research. It also pursues a policy for the lodgement with trial registries of specified details of Phase III clinical trials. Failure to comply would jeopardise publication of trial outcomes in ICMJE member journals. This policy has resulted in the coming on stream of trial registries, international agreement on trial minimal datasets and compliance with trial registration requirements.

Ghost authorship in industry-initiated randomised trials

BACKGROUND

Ghost authorship, the failure to name, as an author, an individual who has made substantial contributions to an article, may result in lack of accountability. The prevalence and nature of ghost authorship in industry-initiated randomised trials is not known.

METHODS AND FINDINGS

We conducted a cohort study comparing protocols and corresponding publications for industry-initiated trials approved by the Scientific-Ethical Committees for Copenhagen and Frederiksberg in 1994-1995. We defined ghost authorship as present if individuals who wrote the trial protocol, performed the statistical analyses, or wrote the manuscript, were not listed as authors of the publication, or as members of a study group or writing committee, or in an acknowledgment. We identified 44 industry-initiated trials. We did not find any trial protocol or publication that stated explicitly that the clinical study report or the manuscript was to be written or was written by the clinical investigators, and none of the protocols stated that clinical investigators were to be involved with data analysis. We found evidence of ghost authorship for 33 trials (75%; 95% confidence interval 60%-87%). The prevalence of ghost authorship was increased to 91% (40 of 44 articles; 95% confidence interval 78%-98%) when we included cases where a person qualifying for authorship was acknowledged rather than appearing as an author. In 31 trials, the ghost authors we identified were statisticians. It is likely that we have overlooked some ghost authors, as we had very limited information to identify the possible omission of other individuals who would have qualified as authors.

CONCLUSIONS

Ghost authorship in industry-initiated trials is very common. Its prevalence could be considerably reduced, and transparency improved, if existing guidelines were followed, and if protocols were publicly available.

Bioethical Issues in Medicinal Chemistry and Drug Treatment

The use of drugs to treat human disease is a pursuit that extends back into our evolutionary ancestors. Drugs are powerful substances with a great capacity to cause harm if misused or overused. Even when used correctly, pharmaceuticals can elicit disputes about their relative harms and benefits in specific situations. The establishment of modern intermediaries – physicians or pharmacists – in the allocation of the most powerful drugs increases the potential for conflict between those who control the resource and those who desire access to it. The size and influence of the pharmaceutical–industrial complex places disproportionate power in those whose interests lie in promoting and expanding pharmaceutical use in society. The expense of certain drugs complicates equitable allocation, and the concentration of pharmaceutical power in Western, industrialized countries promotes research and drug discovery disproportionately for diseases that are prevalent in the wealthier nations. The increasing sophistication of drug action challenges the traditional model of using drugs as a means to treat pathological conditions and processes, and raises the specter of lifestyle and enhancement uses of pharmaceuticals. New means of drug discovery – such as the use of stem cells – have elicited debate about the relative values placed on the status of the embryo and the potential treatment for intractable conditions that could result from stem cell research. Finally, the overall emphasis on drugs as the first line defense against what ails us has provoked some societal soul-searching. In this chapter, we review some of the ethical issues attendant to drug production and distribution, including issues of safety, justice, economic inequality, and the changing demands for drugs that exceed therapeutic uses. Suggestions are made to make pharmaceutical companies more responsive to these issues and to make oversight bodies more responsible for their roles.

Does industry sponsorship undermine the integrity of nutrition research?

Drug companies have tried to influence the scientific record so as to make their products look healthier. Are food companies doing the same?

Financial considerations in the conduct of multi-centre randomised controlled trials: evidence from a qualitative study

BACKGROUND

Securing and managing finances for multicentre randomised controlled trials is a highly complex activity which is rarely considered in the research literature. This paper describes the process of financial negotiation and the impact of financial considerations in four UK multicentre trials. These trials had met, or were on schedule to meet, recruitment targets agreed with their public-sector funders. The trials were considered within a larger study examining factors which might be associated with trial recruitment (STEPS).

METHODS

In-depth semi-structured telephone interviews were conducted in 2003-04 with 45 individuals with various responsibilities to one of the four trials. Interviewees were recruited through purposive and then snowball sampling. Interview transcripts were analysed with the assistance of the qualitative package Atlas-ti.

RESULTS

The data suggest that the UK system of dividing funds into research, treatment and NHS support costs brought the trial teams into complicated negotiations with multiple funders. The divisions were somewhat malleable and the funding system was used differently in each trial. The fact that all funders had the potential to influence and shape the trials considered here was an important issue as the perspectives of applicants and funders could diverge. The extent and range of industry involvement in non-industry-led trials was striking. Three broad periods of financial work (foundation, maintenance, and resourcing completion) were identified. From development to completion of a trial, the trialists had to be resourceful and flexible, adapting to changing internal and external circumstances. In each period, trialists and collaborators could face changing costs and challenges. Each trial extended the recruitment period; three required funding extensions from MRC or HTA.

CONCLUSION

This study highlights complex financial aspects of planning and conducting trials, especially where multiple funders are involved. Recognition of the importance of financial stability and of the need for appropriate training in this area should be paralleled by further similar research with a broader range of trials, aimed at understanding and facilitating the conduct of clinical research.

Informed consent for therapy and research in continuous renal replacement therapy: an international survey

OBJECTIVE

To study the approach of health care workers (HCW) to informed consent for therapy and research in the field of continuous renal replacement therapy (CRRT).

DESIGN

Administration of questionnaire.

SETTING

Two International Courses on Critical Care Nephrology (CCN) held in Vicenza and Melbourne.

PARTICIPANTS

Eight hundred and twenty one course participants.

RESULTS

We obtained 349 analysable questionnaires (42.5% of participants). Only 22.5% of responders always obtain informed consent for CRRT; 70.3% just inform patients/relatives without seeking consent, 7.1% never obtain informed consent. In ICU patients, informed consent is considered 'good, correct and feasible' for therapy and for research by only 13% and 27% of responders, respectively. Consent for clinical research obtained from the next of kin or legal guardian is considered good, correct and feasible' by 56.3% of respondents, while 39.1% believe that next of kin or legal guardians can not really make informed decisions. Finally, nearly half of responders think that present rules hamper research in ICU. For many questions, significant variability of responses was found according to profession, specialty and origin of responders.

CONCLUSIONS

In the field of CRRT, stated practice, beliefs and currently accepted ethical standards vary greatly according to profession, specialty and origin. A significant disagreement between what is widely promoted to be the 'correct' approach and what is currently done is evident.

Ensaios clínicos: capacitação nacional para avaliação de medicamentos e vacinas

O trabalho apresenta uma análise da capacitação dos centros de pesquisa clínica brasileiros para realizar ensaios voltados para a avaliação de medicamentos e vacinas, como suporte ao desenvolvimento de novos produtos. Utiliza bases de dados públicas para a quantificação dos ensaios realizados e entrevistas com patrocinadores e centros de pesquisa clínica para a análise das competências envolvidas na sua realização. Conclui que, embora a capacitação nacional seja alta na realização de ensaios na fase III e razoável nas fases II e IV, ainda é incipiente na fase I, na qual existem poucos centros com experiência. É maior na execução da pesquisa do que no seu desenho. Este perfil foi forjado em resposta à demanda das multinacionais farmacêuticas, majoritária nos últimos anos. Entretanto, é diferente daquele demandado pelos empreendimentos nacionais, que inclui competências no desenho do ensaios, e precisaria ser ajustado para atendê-los, no caso da demanda nacional aumentar, seja por estudos de avaliação tecnológica governamentais (para subsidiar a política de assistência - área que está sendo enfatizada pelo governo federal), seja pelo desenvolvimento de novos medicamentos, seja até para a regularização da situação dos produtos similares atualmente no mercado. No caso dos medicamento genéricos e, mais recentemente, dos medicamentos similares, a regulamentação criou uma firme demanda por testes de bioequivalência e biodisponibilidade por parte das empresas nacionais. Poucos centros, entretanto, a estão atendendo: 78% dos estudos realizados em 2005 foram realizados por 5 dos 24 centros nacionais credenciados pela Anvisa para tal. São apresentadas propostas para o fortalecimento do setor.

BiDil: assessing a race-based pharmaceutical

Isosorbide and hydralazine in a fixed-dose combination (BiDil) has provoked controversy as the first drug approved by the Food and Drug Administration marketed for a single racial-ethnic group, African Americans, in the treatment of congestive heart failure. Family physicians will be better prepared to counsel their patients about this new drug if they understand a number of background issues. The scientific research leading to BiDil's approval tested the drug only in African American populations, apparently for commercial reasons, so the drug's efficacy in other populations is unknown. Race as a biological-medical construct is increasingly controversial; BiDil offers a good example of how sociocultural factors in disease causation may be overlooked as a result of an overly simplistic assumption of a racial and hence presumed genetic difference. Past discrimination and present disparities in health care involving African American patients are serious concerns, and we must welcome a treatment that promises to benefit a previously underserved group; yet the negative aspects of BiDil and the process that led to its discovery and marketing set an unfortunate precedent. Primary care physicians should be aware of possible generic equivalents that will affect the availability of this drug for low-income or uninsured patients.

Financial ties between DSM-IV panel members and the pharmaceutical industry

BACKGROUND

Increasing attention has been given to the transparency of potential conflicts of interest in clinical medicine and biomedical sciences, particularly in journal publishing and science advisory panels. The authors examined the degree and type of financial ties to the pharmaceutical industry of panel members responsible for revisions of the Diagnostic and Statistical Manual of Mental Disorders(DSM).

METHODS

By using multimodal screening techniques the authors investigated the financial ties to the pharmaceutical industry of 170 panel members who contributed to the diagnostic criteria produced for the DSM-IV and the DSM-IV-TR.

RESULTS

Of the 170 DSM panel members 95 (56%) had one or more financial associations with companies in the pharmaceutical industry. One hundred percent of the members of the panels on 'Mood Disorders' and 'Schizophrenia and Other Psychotic Disorders' had financial ties to drug companies. The leading categories of financial interest held by panel members were research funding (42%), consultancies (22%) and speakers bureau (16%).

CONCLUSIONS

Our inquiry into the relationships between DSM panel members and the pharmaceutical industry demonstrates that there are strong financial ties between the industry and those who are responsible for developing and modifying the diagnostic criteria for mental illness. The connections are especially strong in those diagnostic areas where drugs are the first line of treatment for mental disorders. Full disclosure by DSM panel members of their financial relationships with for-profit entities that manufacture drugs used in the treatment of mental illness is recommended.

Gendering the migraine market: Do representations of illness matter?

Migraine is a common, debilitating and costly disorder. Yet help-seeking for and rates of diagnosis of migraine are low. Drawing on ethnographic observations of pharmaceutical marketing practices at professional headache conferences and a content analysis of migraine advertising, principally in the USA, this paper demonstrates: (1) that the pharmaceutical industry directs its marketing of migraine medication to women; and (2) as part of this strategy, pharmaceutical advertisements portray women as the prototypical migraine sufferer, through representations that elicit hegemonic femininity. This strategy creates the impression that migraine is a "women's disorder", which, in turn, exacerbates gender bias in help seeking and diagnosis of migraine and reifies presumptions about the epidemiology of the disorder. I conclude that these pharmaceutical marketing practices have a paradoxical effect: even as they educate and raise awareness about migraine, they also create barriers to help seeking and diagnosis.

Viewpoint: the elephant in medical professionalism's kitchen

The rise of the corporation within health care during the 1980s and early 1990s was met by organized medicine with a deluge of editorials, articles, and books that identified a singular enemy--commercialism--and depicted it as corrosive of, and antithetical to, medical professionalism. Medicine's ire proved prognostic as scores of highly publicized corporate-medical scandals began to crater the landscape of a rapidly emerging "medical marketplace." Medicine's main weapon in this counteroffensive was a renewed call to medical professionalism. Numerous organizations hosted conferences and underwrote initiatives to define, measure, and ultimately inculcate professionalism as a core medical competency. Nonetheless, an examination of medicine's overall response to the threat of commercialism reveals inconsistencies and schisms between these praiseworthy efforts and a parallel absence of action at the community practitioner and peer-review levels. The most recent salvo in this war on commercialism is a policy proposal by influential medical leaders who call for an end to the market incentives linking academic health centers and medical schools with industry. These forthright proposals nevertheless appear once again not to address the heartbeat of professional social control: community-based peer review, including a vigorous and proactive role by state medical boards. The author concludes by examining the implications of a professionalism bereft of peer review and explores the societal-level responsibilities of organized medicine to protect, nurture, and expand the role of the physician to maintain the values and ideals of professionalism against the countervailing social forces of the free market and bureaucracy.

Does a selective cyclooxygenase-2 inhibitor (tiracoxib) induce clinically sufficient suppression of adenomas in patients with familial adenomatous polyposis? A randomized double-blind placebo-controlled clinical trial

BACKGROUND

There have been few placebo-controlled randomized double-blind studies of the clinical effects of selective cyclooxygenase-2 (COX-2) inhibitors on the regression of colorectal tumors. This study was designed to examine the regressive effect of a selective COX-2 inhibitor, tiracoxib (JTE-522), on colorectal polyps in patients with familial adenomatous polyposis (FAP), and its safety.

METHODS

Sixty-one patients with FAP diagnosed by Japanese criteria were assigned randomly to receive placebo or JTE-522, at either 150 mg or 200 mg, once daily orally for 26 weeks. Prior to and at the end of the medication period, endoscopy was performed. Adenomas located near an india-ink tattoo injected at the first colonoscopy were identified and measured. The response variables were the percent changes from the baseline in polyp numbers and in specified polyp diameters. Any adverse events that appeared in at least four persons were taken into consideration and compared between the JTE-522 treatment groups and the placebo group.

RESULTS

No change in polyp number (median, 0) was observed in any of the three groups. There were no differences between the placebo group and the two treatment groups in the change in polyp size. JTE-522 was well tolerated.

CONCLUSION

Our findings, in keeping with other reports on COX-2 inhibitors, indicated that the inhibition of a COX-2 with a moderate dose of a selective COX-2 inhibitor did not induce clinically sufficient regression of adenomas in patients with FAP in a limited (6-month) medication period.