Beyond moral outrage--weighing the trade-offs of COI regulation

Global matters of epidemiology and the ethical challenges of addressing the health of populations

PURPOSE

The American College of Epidemiology (ACE) held its 2022 Annual Meeting, September 8-11, with a conference theme of 'Pandemic of Misinformation: Building Trust in Epidemiology'. The ACE Ethics Committee hosted a symposium session in recognition of the global spotlight placed on epidemiology and public health due to the COVID-19 crisis. The ACE Ethics Committee invited previous Chairs of the Ethics Committee and current President of the International Epidemiological Association to present at the symposium session. This paper aims to highlight the ethical challenges presented during the symposium session.

METHODS

Three speakers with diverse backgrounds representing expertize from the fields of ethics, epidemiology, public health, clinical trials, pharmacoepidemiology, statistics, law, and public policy, covering perspectives from the U.S., Europe, and Southeast Asia were selected to present on the ethical challenges in epidemiology and public health applying a global theme. Dr. D. Weed presented on 'Causation, Epidemiology and Ethics'; Dr. C.M. Pandey presented on the 'Ethical Challenges in the Practice of Digital Epidemiology'; and Dr. J. Acquavella presented on 'Departures from Scientific Objectivity: A Cause of Eroding Trust in Epidemiology.'

RESULTS

The collective goal to improve the public's health was a mutually shared theme across the three distinct areas. We highlight the common ethical guidance and principle-based approaches that have served epidemiology and public health in framing and critical analysis of novel challenges, including autonomy, beneficence, justice, scientific integrity, duties to the profession and community, and developing and maintaining public trust; however, gaps remain in how best to address health inequalities and the novel emergence and pervasiveness of misinformation and disinformation that have impacted the health of the global community. We introduce an ethical framework of translational bioethics that places considerations of the social determinants of health at the forefront.

CONCLUSIONS

The COVID-19 pandemic required an expedited public health response and, at the same time, placed the profession of epidemiology and public health, its system, and structures, under the microscope like never before. This article illustrates that revisiting our foundations in research and practice and orienting contemporary challenges using an ethical lens can assist in identifying and furthering the health of populations globally.

Pharmaceutical industry payments and delivery of non-recommended and low value cancer drugs: population based cohort study

OBJECTIVE

To estimate the association between oncologists' receipt of payments from the pharmaceutical industry and delivery of non-recommended or low value interventions among their patients.

DESIGN

Cohort study.

SETTING

Fee-for-service Medicare claims.

PARTICIPANTS

Medicare beneficiaries with a diagnosis of incident cancer (new occurrence of a cancer diagnosis code in proximity to claims for cancer treatment, and no such diagnosis codes during a ≥1 year washout period) during 2014-19, who met additional requirements identifying them as at risk for one of four non-recommended or low value interventions: denosumab for castration sensitive prostate cancer, granulocyte colony stimulating factors (GCSF) for patients at low risk for neutropenic fever, nab-paclitaxel for cancers with no evidence of superiority over paclitaxel, and a branded drug in settings where a generic or biosimilar version was available.

MAIN OUTCOME MEASURES

Receipt of the non-recommended or low value drug for which the patient was at risk. The primary association of interest was the assigned oncologist's receipt of any general payments from the manufacturer of the corresponding non-recommended or low value drug (measured in Open Payments) within 365 days before the patient's index cancer date. The two modeling approaches used were general linear model controlling for patients' characteristics and calendar year, and general linear model with physician level indicator variables.

RESULTS

Oncologists were in receipt of industry payments for 2962 of 9799 patients (30.2%) at risk for non-recommended denosumab (median $63), 76 747 of 271 485 patients (28.3%) at risk for GCSF (median $60); 18 491 of 86 394 patients (21.4%) at risk for nab-paclitaxel (median $89), and 4170 of 13 386 patients (31.2%) at risk for branded drugs (median $156). The unadjusted proportion of patients who received non-recommended denosumab was 31.4% for those whose oncologist had not received payment and 49.5% for those whose oncologist had (prevalence difference 18.0%); the corresponding values for GCSF were 26.6% v 32.1% (5.5%), for nab-paclitaxel were 7.3% v 15.1% (7.8%), and for branded drugs were 88.3% v 83.5% (-4.8%). Controlling for patients' characteristics and calendar year, payments from industry were associated with increased use of denosumab (17.5% (95% confidence interval 15.3% to 19.7%)), GCSF (5.8% (5.4% to 6.1%)), and nab-paclitaxel (7.6% (7.1% to 8.1%)), but lower use of branded drugs (-4.6% (-5.8% to -3.3%)). In physician level indicator models, payments from industry were associated with increased use of denosumab (7.4% (2.5% to 12.2%)) and nab-paclitaxel (1.7% (0.9% to 2.5%)), but not with GCSF (0.4% (-0.3% to 1.1%)) or branded drugs (1.2% (-6.0 to 8.5%)).

CONCLUSIONS

Within some clinical scenarios, industry payments to physicians are associated with non-recommended and low value drugs. These findings raise quality of care concerns about the financial relationships between physicians and industry.

When Characteristics of Clinical Trials Require Per-Protocol as Well as Intention-to-Treat Outcomes to Draw Reliable Conclusions: Three Examples

Under exceptional circumstances, including high rates of protocol non-compliance, per-protocol (PP) analysis can better indicate the real-world benefits of a medical intervention than intention-to-treat (ITT) analysis. Exemplifying this, the first randomized clinical trial (RCT) considered found that colonoscopy screenings were marginally beneficial, based upon ITT analysis, with only 42% of the intervention group actually undergoing the procedure. However, the study authors themselves concluded that the medical efficacy of that screening was a 50% reduction in colorectal cancer deaths among that 42% PP group. The second RCT found a ten-fold reduction in mortality for a COVID-19 treatment drug vs. placebo by PP analysis, but only a minor benefit by ITT analysis. The third RCT, conducted as an arm of the same platform trial as the second RCT, tested another COVID-19 treatment drug and reported no significant benefit by ITT analysis. Inconsistencies and irregularities in the reporting of protocol compliance for this study required consideration of PP outcomes for deaths and hospitalizations, yet the study coauthors refused to disclose them, instead directing inquiring scientists to a data repository which never held the study's data. These three RCTs illustrate conditions under which PP outcomes may differ significantly from ITT outcomes and the need for data transparency when these reported or indicated discrepancies arise.

SAGES perspective: professional medical associations, commercial interests, and conflicts of interest

BACKGROUND

Professional medical associations (PMAs) have an essential role in advancing medical care and health. PMAs promote skills training, clinical standards, and other important educational activities. Most often, PMAs are not-for-profit entities that rely upon funding from industry to help cover the costs of these valuable activities. Equally important, innovation and progress in surgery require physician collaboration with industry throughout the product development process. SAGES has opined that, with appropriate Conflict of Interest (COI) disclosure and management processes, PMA educational activities can be both scientifically and ethically sound.

METHODS

SAGES has developed and implemented comprehensive and stringent processes for managing potential COI within the organization, at the annual meeting, and in developing educational offerings. This document reviews the SAGES COI processes and results 2009-2021.

RESULTS

Implementation of the SAGES COI disclosure and management processes reduced the reported perceived incidence of bias at the annual meeting from 4.4-6.2% (2008-2010) to 1.2-2.2% (2011-2013). Recent comparison of reported disclosures revealed a rise in number of speakers with financial relationships and an increase in reporting of disclosures in presentations without an associated increase in need for conflict resolution by the COI committee. Despite good overall adherence to COI policies, SAGES was recently cited for non-compliance with ACCME standards related to inclusion of faculty with ownership interest. This experience highlighted the potential for discordance in the interpretation of whether disclosures relate to specific CME content. SAGES COI processes have since been updated to reflect the more stringent 2020 ACCME Standards that exclude speakers and planners with ownership interest from any CME activity.

CONCLUSIONS

The SAGES experience with disclosure and mitigation of financial relationships highlights the challenges of validating the accuracy of physician disclosures and establishing the relevance of financial relationships to the content of accredited educational activities. SAGES will continue to streamline its COI disclosure process with specific focus on aligning all financial disclosures among the various reporting platforms.

Community physicians' attitudes towards meetings with representatives of pharmaceutical companies: a pilot study

BACKGROUND

Marketing by pharmaceutical companies has become an increasingly controversial issue for the medical community and the public. This controversy stems from the potential influence that pharmaceutical companies can wield through marketing on the medical community. This study assesses community physicians' attitudes towards pharmaceutical companies and their representatives to get a better understanding of how their activities affect daily work in community clinics.

METHODS

A cross-sectional anonymous questionnaire-based study of 170 community physicians in southern Israel was conducted via convenience sampling. The questionnaire was designed to assess physicians' attitudes about the nature of their relationships with representatives of pharmaceutical companies and possible associations with physicians' demographic and professional profiles. The questionnaire was distributed, at weekly staff meetings in the study clinics, to a convenience sample of physicians, who agreed to participate in the study.

RESULTS

Most physicians did not have an extreme attitude on interactions with representatives of pharmaceutical companies. Interestingly, while they thought that pharmaceutical companies play an important role in medical progress, they did express concern regarding the risk of misleading information. While they believed that interactions between physicians and representatives of pharmaceutical companies had a negative effect on the clinic workflow, they were not in favor of prohibiting such interactions. Physicians who graduated from medical schools in Israel held a less sympathetic position towards these interactions.

CONCLUSION

The anticipated heterogeneous attitudes of community-based physicians on interactions with representatives of pharmaceutical companies reflect an inherent complex relationship, with aspects that are specific to the Israeli medical field. Interestingly, physicians trained in other countries than Israel also have divergent attitudes, further affecting the socio-cultural impact on practitioner's attitudes towards this intricate and often politicized topic. Open professional dialogue and targeted educational programs on the physician-pharmaceutical relationship, with more explicit regulation, could potentially ease the discomfort experienced by physicians, especially in the Israeli context and result in a clearer framework of interaction that would leverage the potential advantages while accounting for ethical and regulatory pitfalls.

Industry Payments to Physicians Are Kickbacks. How Should Stakeholders Respond?

Payments from the pharmaceutical industry to US physicians are common. In determining which payments rise to the level of an illegal kickback under the Anti-Kickback Statute (AKS), the Department of Health and Human Services' Office of Inspector General (OIG) has stated in nonbinding guidance that influencing or "swaying" physician prescribing is key. OIG has highlighted as a compliance standard the Pharmaceutical Research and Manufacturers of America Code on Interactions with Health Professions, which stipulates that permissible payments are those that do not interfere with prescribing. However, recent evidence has shown that most payments influence physician prescribing, driving higher prescription drug costs by increasing use of brand-name and low-value drugs. This evidence implies that many payments that are currently commonplace could be subject to prosecution under AKS. Given that these payments increase costs to patients and the health care system, there is a public interest in curtailing them. This article proposes a range of actions available to stakeholders-including industry, providers, regulators, and payers-to mitigate the cost-increasing effect of industry payments to physicians.

Health Care Clinicians and Product Promotion by Industry

Medical pharmaceutical and device manufacturers are essential in making products that benefit patients, and collaboration between health care clinicians and the industry is necessary for the design and manufacture of these medical products. However, health care clinicians must recognize that their duties and the interests of the industry may at times diverge. Relationships with the industry, even seemingly minor ones, have the potential to shape the decisions made on behalf of patients. The marketing divisions of pharmaceutical and medical device firms view health care clinicians as targets of their efforts, and some of the interactions that occur between the industry and health care clinicians have the potential to alter decision making in ways that may not necessarily benefit patients. Health care clinicians have an ethical duty to recognize situations and marketing strategies that are designed to influence their choice of diagnostic and therapeutic options for their patients. At a minimum, health care clinicians should be aware of the techniques used to attempt to alter their behavior and guard against them.

Conflict of Interest in Research and Publication: Has the Pendulum Swung Too Far?

Traditionally scientists and industry have collaborated to contribute to the development of new drugs, biologics, and medical devices. Conflicts of interest (COI) may develop among surgeons and academic researchers, especially during the process of refinement of techniques and the marketing and sale of devices. Dramatic examples of COI occurred over the last 50 years, leading to strict regulations designed to reduce COI at research institutions. The International Committee of Medical Journal Editors created COI guidelines to help authors and editors ensure clear, reproducible, and unbiased medical articles. The Physician Payments Sunshine Act was designed to increase transparency of financial relationships between physicians and industry. However, in some cases authors and scientists are not obligated to fully disclose their COI. Only direct payments are required to be reported, not indirect payments to faculty at large academic institutions, allowing some to take advantage of the exceptions to the disclosure requirements whereas others must disclose payment for their work effort. Based on prominent scandals, regulations aimed at reducing industry influence in research and publication may fail to recognize the potential benefits of collaboration and produce a narrow-minded view of trust. Where should an editorial board or an academic institution draw the line?

Personal Payments from Pharmaceutical Companies to Authors of Oncology Clinical Practice Guidelines

BACKGROUND

Oncologists who author clinical practice guidelines frequently have financial relationships with the pharmaceutical industry. It is unknown whether participation on clinical practice guideline committees is associated with differences in the amounts of industry money received.

MATERIALS AND METHODS

We conducted a nested case-control study from August 2013 to December 2018. We manually abstracted membership records of National Comprehensive Cancer Network (NCCN) Guidelines committees for the 20 most common cancers and linked to Open Payments. The study sample included medical oncologists selected to join an NCCN Guidelines committee ("joiners") during the study period. Joiners were matched 1:2 to medical oncologists who had no participation on NCCN committees (controls) by gender, NCCN institution, and medical school graduation year. We performed difference-in-differences (DiD) estimation to assess whether selection to an NCCN committee was associated with the dollar value of payments received from industry, using generalized estimating equations to address correlation between matched pairs and between repeated observations of the same pair.

RESULTS

During the study period, 54 physicians joined an NCCN Guidelines committee. These physicians received more payments than matched controls in the year prior to joining ($11,259 vs. $3,427; p = .02); this difference did not increase in the year after joining (DiD = $731; p = .45).

CONCLUSION

Medical oncologists selected to NCCN Guidelines committees had greater financial ties to industry than their peers. The potential influence of industry in oncology clinical practice guidelines may be reduced through the selection of committee members with fewer ties to industry.

IMPLICATIONS FOR PRACTICE

Oncologists who author clinical practice guidelines frequently have financial conflicts of interest with the pharmaceutical industry. This creates concern about the potential for industry influence on guidelines. However, it is unknown whether oncologists who author guidelines have greater industry relationships than their peers. This study compared medical oncologists who were newly selected to join a National Comprehensive Cancer Network (NCCN) Guidelines panel with medical oncologists at the same institutions and at similar career stages. At the time they joined, oncologists joining NCCN Guidelines panels had received more than three times the dollar value of industry payments than their peers. The potential for industry influence may be reduced by the selection of less-conflicted panel members.

Characteristics and conflicts of interest at Food and Drug Administration Gastrointestinal Drug Advisory Committee meetings

Introduction

The United States Food and Drug Administration (FDA) Gastrointestinal Drug Advisory Committee (GIDAC) is involved in gastrointestinal drug application reviews. Characteristics and conflicts of interest (COI) in GIDAC meetings are not well described. This study analyzed FDA GIDAC meetings and characteristics that predict recommendations.

Methods

In this cross-sectional study, all publicly available GIDAC meetings where proposed medications were voted on were included. Data were collected regarding indications, medication sponsor, primary efficacy studies, and voting member characteristics (e.g. committee membership, COI). Univariate analyses were conducted at per-meeting and per-vote levels to assess for predictors of committee recommendation and individual votes respectively.

Results

Thirty-four meetings with 476 individual votes from 1998–2018 were included. Twenty-three (68%) proposals were recommended for approval and 25 (74%) received FDA approval. Most proposals involved >1 primary study (n = 27, 79%). At least one voting member had a COI in 24 (71%) of 34 meetings. Twelve (35%) meetings had at least one sponsor COI. Among 476 individual votes, 74 (15.5%) involved a COI, with 33 (6.9%) sponsor COI. COI decreased significantly over time, with fewer COI in 2006–2010, 2011–2015, and 2016–2020 compared to 1996–2000 and 2001–2005 (p<0.01). There were no significant associations between pre-defined predictors, including COI, and committee level recommendations or individual votes (p>0.05 for all univariate analyses).

Conclusions

The GIDAC reviewed 34 proposals from 1998–2018. The majority were recommended for approval and later approved by the FDA, highlighting the GIDAC’s prominence in the regulatory process. COI are present among GIDAC panelists but decreasing over time and not associated with recommendations.

Key opinion leaders - a critical perspective

Enormous progress has been made in the field of rheumatology in the past several decades, historically led by publicly funded academic innovators but in more recent times with much greater involvement of the pharmaceutical industry. This shift in resources has created a complex new model for reinvestment in the medical community in which the vast majority of private funds are redirected towards influencing the prescription behaviour of practitioners through 'key opinion leaders', with the main purpose of enhancing and perpetuating profit rather than innovation and critical thinking, and often at the expense of partnerships with scientists (that is, basic and translational researchers) and academic collaborations. This new episteme brings multiple opportunities to rethink approaches to sustaining long-term critical research in the field, ultimately maximizing the return on investment: scientific knowledge for the benefit of patients and society. Central to such strategies should be the rebalancing of academia-industry partnerships towards academic research and the involvement of 'innovation and knowledge leaders', rather than mostly key opinion leaders.

Association of Mandatory Disclosure Policies and Laws With Physician-Industry Financial Relationships

Importance

Beside the goal of increasing transparency to the public, disclosure policies and laws have been established with a goal to also reduce ethically questionable financial relationships between physicians and the medical industry. Data on these relationships should be reviewed to understand the association between these policies and laws and the attainment of reduced relationships.

Objective

To assess whether disclosure policies and laws have been associated with a decrease in financial disclosure reporting by physicians.

Design, Setting, and Participants

This cross-sectional study uses yearly data from 2008 through 2015 from the participants in the American Academy of Ophthalmology's Annual Meeting. Trends in financial disclosures over time were investigated for the association of disclosure policies and laws with potentially beneficial, as well as ethically questionable physician-industry ties. Linear regression models were used to estimate the annual change in financial disclosures and are reported with 95% CIs.

Exposures

Disclosure policies and laws.

Main Outcomes and Measures

The annual aggregate financial disclosures by type (ie, consultant, lecturer, employee, grant support, equity owner, patent holder).

Results

Financial disclosures increased from 3966 in 2008 to 5266 in 2015 (P < .001). The number of disclosures reported in the categories consultant, equity owner, patents, and grant support all increased from 2008 to 2015 (consultant disclosures, 121 [95% CI, 88-155] per year; P < .001; equity owner disclosures, 32 [95% CI, 22-42] per year; P < .001; patent disclosures, 19 [95% CI, 13-26] per year; P < .001; grant support disclosures, 78 [95% CI, 48-107] per year; P < .001), while the employee and lecturer categories did not change significantly. The percentage of financial disclosures in the lecturer category decreased relative to the total (estimate, -1.1% [95% CI, -1.3% to -0.8%] per year; P < .001), owing to the number of financial disclosures for this category remaining stable while most other types increased.

Conclusions and Relevance

Disclosure was not associated with a chilling effect (decrease in financial disclosures associated with potentially beneficial physician-industry ties). Disclosure was associated with a possible disinfecting effect, whereby the percentage of ethically questionable disclosures (ie, lecturers) decreased, although the frequency remained stable. A permissive effect (physicians becoming more inclined to having industry relationships) was also observed. Thus, disclosure rules should be enhanced or alternative approaches to disclosure reconsidered to promote a decrease in ethically questionable relationships.

Developing interactions with industry in rare diseases: lessons learned and continuing challenges

The National Institutes of Health (NIH) established the Rare Diseases Clinical Research Network to address the unique challenges of performing research on rare diseases. The Urea Cycle Disorders Consortium (UCDC) was one of the original ten consortia established. The UCDC represents a unique partnership among clinicians, patients, and the NIH with a primary goal of increasing the development of therapeutics that improve patient outcomes for persons affected with a UCD. Based in part on financial incentives associated with the Orphan Drug Act biopharmaceutical and investment entities have an intense interest in engaging with research consortia like the UCDC, which have compiled potentially valuable longitudinal data characterizing outcomes in a relatively large number of affected individuals. We describe the UCDC experience and the bases for evaluating partnerships with such private entities. We review early industry interactions, the development of policies and procedures, and describe the establishment of an Industry Relations Committee, including guiding principles. Challenges encountered, particularly in the transition when products are approved, and potential solutions are discussed. By building a framework for industry partnerships that guides us in resolving inevitable challenges, we can enthusiastically pursue novel and promising collaborations that can lead to breakthroughs in therapeutic interventions for patients.

Association of author’s financial conflict of interest with characteristics and outcome of rheumatoid arthritis randomized controlled trials

Objective

To examine the prevalence, types and temporal trends of reported financial conflicts of interest (FCOIs) among authors of drug therapy randomized controlled trials (RCTs) for RA and their association with study outcomes.

Methods

We identified original, non–phase 1, parallel-group, drug therapy RA RCTs published in the years 2002–03, 2006–07, and 2010–11. Two investigators independently obtained trial characteristics data. Authors’ FCOIs were classified as honoraria/consultation fees receipt, employee status, research grant, and stock ownership. Multivariable logistic regression was performed to identify whether FCOIs were independently associated with study outcome.

Results

A total of 146 eligible RCTs were identified. Of these, 83 (58.4%) RCTs had at least one author with an FCOI [employee status: 63 (43.2%), honoraria/consultation fees receipt: 49 (33.6%), research grant: 30 (20.5%), and stock ownership: 28 (19.2%)]. A remarkable temporal increase in reporting of honoraria/consultation fees receipt, research grant, and stock ownership was seen. The reporting of any FCOI itself was not associated with positive outcome [50/73 (68.5%) with author FCOI vs 36/52 (69.2%) without author FCOI, P = 0.93]. However, honoraria/consulting fees receipt was independently associated with increased likelihood of a positive outcome [adjusted odds ratio (95% CI) of 3.24 (1.06–9.88)]. In general, trials with FCOIs were significantly more likely to be multicentre, have larger enrolment, use biologic or a small molecule as the experimental intervention, and have better reporting of some methodological quality measures.

Conclusion

FCOI reporting in RA drug RCT authors is common and temporally increasing. Receipt of honoraria/consulting fees was independently associated with a positive study outcome.

Vaccine Hesitancy, History, and Human Nature: The 2018 Stanley A. Plotkin Lecture

Navigating the waters of vaccine hesitancy requires a view towards history and a deep understanding of how humans think. Getting children vaccinated is as much, or more, about connecting with people as it is about communicating scientific information.

Effect of different financial competing interest statements on readers' perceptions of clinical educational articles: a randomised controlled trial

OBJECTIVES

To investigate how different competing interest (COI) statements affect clinical readers' perceptions of education articles.

DESIGN

Randomised controlled trial.

SETTING AND PARTICIPANTS

Random sample of UK doctors.

INTERVENTIONS

We created four permutations of each of two clinical reviews (on gout or dyspepsia), which varied only in terms of the COI statement. Volunteers were blinded and randomised to receive one review and asked to complete a questionnaire after reading it. Blinded factorial analyses of variance and analyses of covariance were carried out to assess the influence of each review and type of COI on outcomes.

PRIMARY AND SECONDARY OUTCOMES

Confidence in the article's conclusions (primary outcome), its importance, their level of interest in the article and their likelihood to change practice after reading it.

RESULTS

Of 10 889 doctors invited to participate, 1065 (10%) volunteered. Of these, 749 (70%) completed the survey. Analysis of covariance (adjusting for age, sex, job type, years since qualification) showed no significant difference between the groups in participants' confidence in the article (gout: p=0.32, dyspepsia: p=0.78) or their rating of its importance (gout: p=0.09, dyspepsia: p=0.79). For the gout review, participants rated articles with advisory board and consultancies COI as significantly less interesting than those with no COI (p=0.028 with Bonferroni correction). Among participants indicating that they treat the condition and that the article's recommendations differed from their own practice, there was no significant difference in likelihood to change practice between groups (gout: p=0.59, n=59; dyspepsia: p=0.56, n=80).

CONCLUSIONS

Doctors' confidence in educational articles was not influenced by the COI statements. Further work is required to determine if doctors do not perceive these COIs as important in educational articles or if they do not pay attention to these statements. More meaningful COI disclosure practices may be needed, which highlight context-specific potential sources of bias to readers.

TRIAL REGISTRATION NUMBER

NCT02548312; Results.

Second victims in health care: current perspectives

Medical errors are a serious public health problem and the third-leading cause of death after heart disease and cancer. Every day, the health care professionals (HCPs) practice their skill and knowledge within excessively complex situations and meet unexpected patient outcomes. These unexpected complications and unintentional errors will always be a part of the medical system due to the universal nature of human fallibility and technology. While not all errors are life-threatening, they can significantly compromise a patient's quality of life. However, the victims of medical error reach far beyond the patient. The second victim (SV), which defined for the first time by Albert Wu in his description of the impact of errors on HCPs by both personally and professionally, is a medical emergency equivalent to post-traumatic stress disorder. When the errors occur, it causes a domino effect including the four groups: the patient and family (first victim), the HCP [SV], the hospital reputation (third victim), and patients who are harmed subsequently (fourth victims). The rights of our patients to safe, reliable, and patient-centered care are critical and most important as a primary and utmost aim of medicine. However, we also have to take care of our own (SVs), especially when we have good people who mean to do well and then find themselves in an emotionally complex situation. There is a need to articulate to the public, politicians, and media how system failure leads to medical error even in hand of well-educated and competent HCPs are given an increasing clinical workload. Furthermore, despite several leading institutions in western countries have developed formal support programs that allow HCPs to cope with their emotional distress by obtaining timely support in an emphatic, confidential, non-judgmental environment, we need to raise awareness of this phenomenon and appropriate institutional responses both to harmed patients and their families and HCPs.

Conflicts of Interest in Clinical Practice Guidelines: Accelerating an Evolution. An Endocrine Society Consensus Statement

An analysis of the Endocrine Society's clinical practice guidelines (CPGs) published from 2010 to 2017-presented by Irwig et al. in the current issue of The Journal of Endocrinology and Metabolism-suggested that the Endocrine Society met five of seven National Academy of Medicine (NAM) standards concerning financial conflicts of interest in CPGs. As current contributors to the Endocrine Society's CPG efforts, we offer additional context related to the 2011 NAM standards and the current environment concerning industry support in medicine, and we comment on the nature of industry support received by the Society's CPG authors according to Irwig and colleagues' analysis of the Centers for Medicare and Medicaid Services' Open Payments database. Perhaps most importantly, we outline the Society's recent and ongoing efforts to enhance the value of its CPGs. Such efforts include a 2016 revision of CPG author conflict of interest rules-a change that was invisible to the investigatory methods used by Irwig et al.-in addition to other processes designed to enhance CPG objectivity. We conclude our commentary by recognizing that good-faith attempts to enhance transparency and to reduce conflicts of interest (real or apparent) in CPGs will ultimately serve the best interests of patients and providers; we confirm the Endocrine Society's resolute commitment to providing high-quality, evidence-based clinical guidance via a CPG development process that faithfully accords with current CPG best practices.

Scientists Still Behaving Badly? A Survey Within Industry and Universities

Little is known about research misconduct within industry and how it compares to universities, even though a lot of biomedical research is performed by-or in collaboration with-commercial entities. Therefore, we sent an e-mail invitation to participate in an anonymous computer-based survey to all university researchers having received a biomedical research grant or scholarship from one of the two national academic research funders of Belgium between 2010 and 2014, and to researchers working in large biomedical companies or spin-offs in Belgium. The validated survey included questions about various types of research misconduct committed by respondents themselves and observed among their colleagues in the last three years. Prevalences of misconduct were compared between university and industry respondents using binary logistic regression models, with adjustments for relevant personal characteristics, and with significance being accepted for p < 0.01. The survey was sent to 1766 people within universities and an estimated 255 people from industry. Response rates were 43 (767/1766) and 48% (123/255), and usable information was available for 617 and 100 respondents, respectively. In general, research misconduct was less likely to be reported by industry respondents compared to university respondents. Significant differences were apparent for one admitted action (gift authorship) and three observed actions (plagiarism, gift authorship, and circumventing animal-subjects research requirements), always with lower prevalences for industry compared to universities, except for plagiarism. This survey, based on anonymous self-report, shows that research misconduct occurs to a substantial degree among biomedical researchers from both industry and universities.

Closed Financial Loops: When They Happen in Government, They're Called Corruption; in Medicine, They're Just a Footnote

Many physicians are involved in relationships that create tension between a physician's duty to work in her patients' best interest at all times and her financial arrangement with a third party, most often a pharmaceutical manufacturer, whose primary goal is maximizing sales or profit. Despite the prevalence of this threat, in the United States and globally, the most common reaction to conflicts of interest in medicine is timid acceptance. There are few calls for conflicts of interest to be banned, and, to our knowledge, no one calls for conflicted practitioners to be reprimanded. Contrast our attitudes in medicine with public attitudes toward financial conflicts among government employees. When enforcement of rules against conflict of interest slackens in the public sector, news organizations investigate and publish their criticism. Yet even when doctors are quoted in the media promoting specific drugs, their personal financial ties to the drug maker are rarely mentioned. Policies for governmental employees are strict, condemnation is strong, and criminal statutes exist (allowing for corruption charges). Yet the evidence that conflict is problematic is, if anything, stronger in medicine than in the public sector. Policies against conflicts of interest in medicine should be at least as strong as those already existing in the public sector.

Differing Perceptions Concerning Research Integrity Between Universities and Industry: A Qualitative Study

Despite the ever increasing collaboration between industry and universities, the previous empirical studies on research integrity and misconduct excluded participants of biomedical industry. Hence, there is a lack of empirical data on how research managers and biomedical researchers active in industry perceive the issues of research integrity and misconduct, and whether or not their perspectives differ from those of researchers and research managers active in universities. If various standards concerning research integrity and misconduct are upheld between industry and universities, this might undermine research collaborations. Therefore we performed a qualitative study by conducting 22 semi-structured interviews in order to investigate and compare the perspectives and attitudes concerning the issues of research integrity and misconduct of research managers and biomedical researchers active in industry and universities. Our study showed clear discrepancies between both groups. Diverse strategies in order to manage research misconduct and to stimulate research integrity were observed. Different definitions of research misconduct were given, indicating that similar actions are judged heterogeneously. There were also differences at an individual level, whether the interviewees were active in industry or universities. Overall, the management of research integrity proves to be a difficult exercise, due to many diverse perspectives on several essential elements connected to research integrity and misconduct. A management policy that is not in line with the vision of the biomedical researchers and research managers is at risk of being inefficient.

Towards Patient-Centered Conflicts of Interest Policy

Financial conflicts of interest exist between industry and physicians, and these relationships have the power to influence physicians' medical practice. Transparency about conflicts matters for ensuring adequate informed consent, controlling healthcare expenditure, and encouraging physicians' reflection on professionalism. The US Centers for Medicare & Medicaid Services (CMS) launched the Open Payments Program (OPP) to publicly disclose and bring transparency to the relationships between industry and physicians in the United States. We set out to explore user awareness of the database and the ease of accessibility to disclosed information, however, as we show, both awareness and actual use are very low. Two practical policies can greatly enhance its intended function and help alleviate ethical tension. The first is to provide data for individual physicians not merely in absolute terms, but in meaningful context, that is, in relation to the zip code, city, and state averages. The second increases access to the OPP dataset by adding hyperlinks from physicians' professional websites directly to their Open Payments disclosure pages. These changes considerably improve transparency and the utility of available data, and can furthermore enhance professionalism and accountability by encouraging physicians to reflect more actively on their own practices.

Health Professionals "Make Their Choice": Pharmaceutical Industry Leaders' Understandings of Conflict of Interest

Conflicts of interest, stemming from relationships between health professionals and the pharmaceutical industry, remain a highly divisive and inflammatory issue in healthcare. Given that most jurisdictions rely on industry to self-regulate with respect to its interactions with health professionals, it is surprising that little research has explored industry leaders' understandings of conflicts of interest. Drawing from in-depth interviews with ten pharmaceutical industry leaders based in Australia, we explore the normalized and structural management of conflicts of interest within pharmaceutical companies. We contrast this with participants' unanimous belief that the antidote to conflicts of interest with health professionals were "informed consumers." It is, thus, unlikely that a self-regulatory approach will be successful in ensuring ethical interactions with health professionals. However, the pharmaceutical industry's routine and accepted practices for disclosing and managing employees' conflicts of interest could, paradoxically, serve as an excellent model for healthcare.

Deciphering the Sunshine Act: Transparency Regulation and Financial Conflicts in Health Care

The Physician Payments Sunshine Act ("Sunshine Act"), enacted to address financial conflicts in health care, is the first comprehensive federal legislation mandating public reporting of payments between drug companies, device manufacturers, and medicine. This article analyzes the Sunshine Act's uneven record, exploring how the law serves as an intriguing example of the uncertain case for transparency regulation in health care. The Sunshine Act's bumpy rollout demonstrates that commanding transparency through legislation can be arduous because of considerable implementation challenges. Capturing all the relevant information about financial relationships and reporting it with sufficient contextual and comparative data has proven disappointingly difficult. In addition, the law suffers from uncertainty and poor design as to the intended audience. Indeed, there is strong reason to believe that it will not significantly impact decision-making of primary recipients like patients. Yet the Sunshine Act nonetheless retains important and perhaps underappreciated value. From the almost four years of information generated, we have learned that industry-medicine financial ties vary significantly by physician specialty, and somewhat by physician gender. In many medical fields the distribution of top dollar payments tends to be heavily skewed to a few recipients, all of which have important implications for optimal management of financial conflicts and for health policy more generally. Accordingly, the Sunshine Act's greatest potential is not guiding decisions of individual patients or physicians, but its downstream effects. This Article traces how secondary audiences, such as regulators, watchdogs, and counsel are already starting to make productive use of Sunshine Act information. Public reporting has, for example, made more feasible linking industry payment information with Medicare reimbursement data. As a result, policymakers can more closely examine correlations between industry spending directed at individual physicians and their prescribing and referral decisions. Moreover, savvy counsel are recognizing that Sunshine Act information provides explosive evidence in private civil litigation and this Article explores the first wave of cases.

Medical student and medical school teaching faculty perceptions of conflict of interest

Background

Attitudes towards conflict of interest (COI) and COI policy are shaped during medical school and influence both the education of medical students and their future medical practice. Understanding the current attitudes of medical students and medical school teaching faculty may provide insight into what is taught about COI and COI policy within the ‘hidden’ medical curriculum. Differences between medical student and medical school teaching faculty perceptions of COI and COI policy have not been compared in detail. The authors surveyed first year medical students and medical school teaching faculty at one academic medical center.

Results

The response rate was 98.7% (150/152) for students and 34.2% (69/202) for faculty. Students were less likely than faculty to agree that lecturers should disclose COI to any learners (4.06 vs. 4.31, p = 0.01), but more likely to agree that COI disclosure decreases the presentation of biased material (3.80 vs. 3.21, p < 0.001). Student and faculty responses for all other questions were not different. Many of these responses suggest student and faculty support for stronger COI policy at academic medical centers.

Conclusions

Students and faculty perceptions regarding COI and COI policy are largely similar, but differ in terms of the perceived effectiveness of COI disclosure. This study also suggests that medical students and medical school teaching faculty support for stronger COI policy at academic medical centers.

Debates about Conflict of Interest in Medicine: Deconstructing a Divided Discourse

The pharmaceutical industry plays an increasingly dominant role in healthcare, raising concerns about "conflicts of interest" (COI) on the part of the medical professionals who interact with the industry. However, there is considerable disagreement over the extent to which COI is a problem and how it should be managed. Participants in debates about COI have become entrenched in their views, which is both unproductive and deeply confusing for the majority of medical professionals trying to work in an increasingly commercialized environment. We used a modified meta-narrative review method to analyse debates about COI in the academic and grey literature. We found two Discourse Models: The Critical Discourse Model sees COI in health and biomedicine as a major problem that both can and should be addressed, while the Defensive Discourse Model argues that current efforts to control COIs are at best unnecessary and at worst harmful. Each model is underpinned by profoundly differing views about how society should be organized-in particular whether market forces should be encouraged or curtailed-and how the dangers associated with market forces should be managed. In order to make any headway, academics and policymakers must recognize that these debates are underpinned by profoundly differing worldviews.

The Relationship of Industry Payments to Prescribing Behavior: A Study of Degarelix and Denosumab

INTRODUCTION

The influence of financial ties to pharmaceutical companies remains controversial. We aimed to assess a potential relationship between pharmaceutical payments and prescription patterns for degarelix and denosumab.

MATERIALS AND METHODS

Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File (Medicare B) data containing 2012 claims compared to OpenPayments (Sunshine Act) data for the second half of 2013. Urologists and medical oncologists who billed Medicare for degarelix or denosumab were cross referenced in both databases and payments were aggregated into a consolidated dataset. Adjusted beneficiary count and total Medicare reimbursement were compared according to receipt of Sunshine payment, and an association between Sunshine payment amount and total Medicare reimbursement was also assessed.

RESULTS

Of the 160 prescribers of degarelix and 1,507 prescribers of denosumab, 91 (57%) and 854 (57%) received Sunshine payment, respectively. Degarelix prescribers who received Sunshine payment had higher median total Medicare reimbursement ($13,257 vs. $9,554, p = 0.01). Denosumab prescribers who received Sunshine payment had both higher median adjusted beneficiary count (55 vs. 50, p < 0.001) and median total Medicare reimbursement ($69,620 vs. $60,732, p < 0.001). On multivariable analysis, both receipt of Sunshine payment (adjusted median difference $5,844, 95% CI $937 - $10,749) and oncology specialty (adjusted median difference $34,380, 95% CI $26,715 - $42,045) were independently associated with total Medicare reimbursement for denosumab.

CONCLUSIONS

In the case of degarelix and denosumab, there is a weak association between pharmaceutical company payments on prescribers' prescription behavior patterns.

Effect of different financial competing interest statements on readers' perceptions of clinical educational articles: study protocol for a randomised controlled trial

INTRODUCTION

Financial ties with industry are varied and common among academics, doctors and institutions. Clinical educational articles are intended to guide patient care and convey authors' own interpretation of selected data. Author biases in educational articles tend to be less visible to readers compared to those in research papers. Little is known about which types of competing interest statements affect readers' interpretation of the credibility of these articles. This study aims to investigate how different competing interest statements in educational articles affect clinical readers' perceptions of the articles.

METHODS AND ANALYSIS

2040 doctors who are members of the British Medical Association (BMA) and receive a copy of the British Medical Journal (The BMJ) each week will be randomly selected and invited by an email to participate in the study. They will be randomised to receive 1 of 2 Clinical Reviews, each with 1 of 4 possible competing interest statements. Versions of each review will be identical except for permutations of the competing interest statement. Study participants will be asked to read their article and complete an online questionnaire. The questionnaire will ask participants to rate their confidence in the conclusions drawn in the article, the importance of the article, their level of interest in the article and their likeliness to change their practice from the article. Factorial analyses of variance and analyses of covariance will be carried out to assess the impact of the type of competing interest statement and Clinical Review on level of confidence, importance, interest and likeliness to change practice.

ETHICS AND DISSEMINATION

The study protocol, questionnaire and letter of invitation to participants have been reviewed by members of The BMJ's Ethics Committee for ethical concerns. The trial results will be disseminated to participants and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT02548312; Pre-results.

Can a good tree bring forth evil fruit? The funding of medical research by industry

BACKGROUND

Systematic reviews analysing the influence of funding on the conduct of research have shown how Conflicts of Interest (COIs) create bias in the production and dissemination of data.

SOURCES OF DATA

The following is a critical analysis of current opinions in respect to COIs created by industry funding of medical research in academic institutions.

AREAS OF AGREEMENT

Effective mechanisms are necessary to manage COIs in medical research, and to prohibit COIs that clearly affect validity of research conduct and outcomes.

AREAS OF CONTROVERSY

While most hold that industry investment in university research is not a barrier to good science, there are questions about how securing funding opportunities might be prioritized over the risks of potential COIs. It is argued that COIs are inherent risks to research integrity, requiring the strengthening of current governance frameworks.

GROWING POINTS

The focus on COIs, created by the ostensibly categorical actions of industry, challenges the evolving research priorities within academic institutions.

AREAS TIMELY FOR DEVELOPING RESEARCH

Less well-defined COIs are equally culpable to financial ones, in terms of the systemic damage they do to science. So, are they appropriately managed as risks within university research settings?