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Astărăstoae V, Rogozea LM, Leaşu FG, Roşca S. Drug Promotions Between Ethics, Regulations, and Financial Interests. Am J Ther 2024; 31:e268-e279. [PMID: 38691666 DOI: 10.1097/mjt.0000000000001754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
BACKGROUND The promotion of the latest medicines produced by the pharmaceutical industry is an important issue both from an ethical point of view (the level of accessibility, the way research is carried out) and from the point of view of marketing and especially from the lobbying issues raised. AREAS OF UNCERTAINTY The ethical dilemmas raised by the promotion of new drugs revolve between the need to discover new molecules important for treating a wide range of diseases and the need to establish a battery of ethical rules, absolutely necessary for regulations in the field to be compliant with all ethical principles. DATA SOURCES A literature search was conducted through PubMed, MEDLINE, Plus, Scopus, and Web of Science (2015-2023) using combinations of keywords, including drugs, medical publicity, and pharma marketing plus ethical dilemma. ETHICS AND THERAPEUTIC ADVANCES The promotion of medicines is governed by advertising laws and regulations in many countries, including at EU level, based on the need for countries to ensure that the promotion and advertising of medicines is truthful, based on information understood by consumers. The ethical analysis of the issues raised is more necessary and complex as the channels used for promotion are more accessible to the population, and the information, easier to obtain, can be the cause of increased self-medication and overeating. Large amounts of money invested in the development of new molecules, but also the risk of scientific fraud through manipulation of data during clinical trials, selective or biased publication of information can have repercussions on the health of the population. CONCLUSIONS The development of new pharmaceutical molecules is necessary to intervene and treat as many conditions as possible, but marketing must not neglect the observance of ethical principles. The promotion of medicines should be the attribute especially of the medical staff, which should also be a mandatory part of the mechanism for approving the marketing methods and means used by the pharmaceutical companies.
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Affiliation(s)
- Vasile Astărăstoae
- Faculty of Medicine, Grigore T Popa University of Medicine & Pharmacy, Iasi, Romania
| | - Liliana M Rogozea
- Basic, Preventive and Clinical Sciences Department, Transilvania University, Brasov, Romania; and
| | - Florin Gabriel Leaşu
- Basic, Preventive and Clinical Sciences Department, Transilvania University, Brasov, Romania; and
| | - Stefan Roşca
- Faculty of Medicine and Pharmacy, Universitatea Dunarea de Jos Galati, Galati, Romania
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2
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Brems JH, Wagner T, Diamant J, Davis AE, Clayton EW. Intellectual conflicts of interest among cardiology and pulmonology clinical practice guidelines. PLoS One 2023; 18:e0288349. [PMID: 37428775 DOI: 10.1371/journal.pone.0288349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 06/19/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Intellectual conflicts of interest (COI), like financial COI, may threaten the validity and trustworthiness of clinical practice guidelines (CPGs). However, comparatively little is known about intellectual COI in CPGs. This study sought to estimate the prevalence of intellectual COI and corresponding management strategies among cardiology and pulmonology CPGs. METHODS We conducted a retrospective document review of CPGs published by cardiology or pulmonology professional societies from the United States, Canada, or Europe from 2018 to 2019 available via the Emergency Care Research Institute, Guidelines International Network, or Medscape databases. We assessed the percentage of authors with an intellectual COI, defined as i) authorship on a study reviewed by the CPG, ii) authorship of a prior editorial related to a CPG recommendation, or iii) authorship of a prior related CPG. Management strategies assessed included use of GRADE methodology, inclusion of a methodologist, and recusals due to intellectual COI. Outcomes were assessed overall and compared between cardiology and pulmonology CPGs. RESULTS Among the 39 CPGs identified (14 cardiology, 25 pulmonology), there were a total of 737 authors, of whom 473 (64%) had at least one intellectual COI. Among all CPGs, a median of 67% (Interquartile Range 50%-76%) of authors had at least one intellectual COI, and COI was more prevalent among cardiology compared with pulmonology CPGs (84% vs 57%, p<0.001). There was variable use of management strategies among the CPGs, including use of GRADE methodology (64% of CPGs), inclusion of a methodologist (49%), and recusals due to intellectual COI (0%). CONCLUSION Intellectual conflicts of interest appear to be highly prevalent and under-reported among cardiology and pulmonology CPGs, which may threaten their validity. Greater attention to and improved management of intellectual COI by CPG-producing organizations is needed.
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Affiliation(s)
- J Henry Brems
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, United States of America
| | - Taylor Wagner
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, United States of America
| | - Julia Diamant
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, United States of America
| | - Andrea E Davis
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Ellen Wright Clayton
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, United States of America
- Law School, Vanderbilt University, Nashville, TN, United States of America
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3
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Ahiskali AS, Drekonja DM, Alpern JD. Conflicts of Interest Among Infectious Diseases Clinical Practice Guideline Authors and the Pharmaceutical Industry. JAMA Netw Open 2023; 6:e238592. [PMID: 37067802 PMCID: PMC10111177 DOI: 10.1001/jamanetworkopen.2023.8592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
This cross-sectional study assesses the prevalence of conflicts of interest (COI) associated with guideline-recommended drugs among Infectious Diseases Society of America clinical practice guideline authors and compliance with the Council on Medical Specialty Societies and Institute of Medicine guidelines.
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Affiliation(s)
| | - Dimitri M Drekonja
- Infectious Diseases Section, Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis
| | - Jonathan D Alpern
- Infectious Diseases Section, Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis
- Department of Infectious Diseases, HealthPartners, Minneapolis, Minnesota
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Mooghali M, Glick L, Ramachandran R, Ross JS. Financial conflicts of interest among US physician authors of 2020 clinical practice guidelines: a cross-sectional study. BMJ Open 2023; 13:e069115. [PMID: 36690402 PMCID: PMC9872463 DOI: 10.1136/bmjopen-2022-069115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/11/2023] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To evaluate the prevalence and accuracy of industry-related financial conflict of interest (COI) disclosures among US physician guideline authors. DESIGN Cross-sectional study. SETTING Clinical practice guidelines published by the Council of Medical Specialty Societies in 2020. PARTICIPANTS US physician guideline authors. MAIN OUTCOME MEASURES Financial COI disclosures, both self-reported and determined using Open Payments data. RESULTS Among 270 US physician authors of 20 clinical practice guidelines, 101 (37.4%) disclosed industry-related financial COIs, whereas 199 (73.7%) were found to have received payments from industry when accounting for payments disclosed through Open Payments. The median payments received by authors during the 3-year period was US$27 451 (IQR, US$1385-US$254 677). Comparing authors' self-disclosures with Open Payments, 72 (26.7%) of the authors accurately disclosed their financial COIs, including 68 (25.2%) accurately disclosing no financial COIs and 4 (1.5%) accurately disclosing a financial COI. In contrast, 101 (37.4%) disclosed no financial COIs and were found to have received payments from industry, 23 (8.5%) disclosed a financial COI but had under-reported payments received from industry, 14 (5.2%) disclosed a financial COI but had over-reported payments received from industry and 60 (22.2%) disclosed a financial COI but were found to have both under-reported and over-reported payments received from industry. We found that inaccurate COI disclosure was more frequent among professors compared with non-professors (81.9% vs 63.5%; p<0.001) and among males compared with females (77.7% vs 64.8%; p=0.02). The accuracy of disclosures also varied among medical professional societies (p<0.001). CONCLUSIONS Financial relationships with industry are common among US physician authors of clinical practice guidelines and are often not accurately disclosed. To ensure high-quality guidelines and unbiased recommendations, more effort is needed to minimise existing COIs and improve disclosure accuracy among panel members.
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Affiliation(s)
- Maryam Mooghali
- General Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale Collaboration for Regulatory Rigor, Integrity, and Transparency (CRRIT), Yale School of Medicine, New Haven, Connecticut, USA
| | - Laura Glick
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Reshma Ramachandran
- Yale Collaboration for Regulatory Rigor, Integrity, and Transparency (CRRIT), Yale School of Medicine, New Haven, Connecticut, USA
- Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Joseph S Ross
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut, USA
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5
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Xun Y, Estill J, Ren M, Wang P, Yang N, Wang Z, Zhu Y, Su R, Chen Y, Akl EA. Developing the RIGHT-COI&F extension for the reporting conflicts of interest and funding in practice guidelines: study protocol. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:717. [PMID: 35845491 PMCID: PMC9279782 DOI: 10.21037/atm-22-2123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/08/2022] [Indexed: 12/08/2022]
Abstract
Background Conflicts of interest (COI) and funding may influence the development of practice guidelines, but there are no internationally endorsed guidelines specifically focusing on the reporting on issues related to COI and funding in practice guidelines. Our aim is to develop an extension of the essential Reporting Items of Practice Guidelines in Healthcare (RIGHT) for COIs and Funding in practice guidelines (i.e., RIGHT-COI&F). Methods We will follow the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) network’s toolkit for developing a reporting guideline in six stages: (I) identifying the need for the extension; (II) registering the project and setting up working groups; (III) collecting the initial items; (IV) reaching consensus on the items to be included; (V) revision and formulation of the final checklist; and (VI) dissemination and implementation. We intend to form a multidisciplinary international team of experts to collect and evaluate the items and plan to complete the full reporting guideline in about 2 years. Discussion The RIGHT-COI&F statement will help guideline developers improve their reporting of issues related to COIs and funding, and subsequently improve the reporting quality of their guidelines. Journals editors, guideline users and evaluators will benefit from a more complete and transparent reporting of COI. Trial Registration We have registered the protocol on the EQUATOR network (https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-other-study-designs/#RIGHT-COI).
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Affiliation(s)
- Yangqin Xun
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Janne Estill
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Mengjuan Ren
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Ping Wang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Nan Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Zijun Wang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Ying Zhu
- The Michael G. DeGroote Cochrane Canada Center, McMaster University, Hamilton, Canada.,The MacGRADE Center, McMaster University, Hamilton, Canada.,Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Canada
| | - Renfeng Su
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Yaolong Chen
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.,Lanzhou University Institute of Health Data Science, Lanzhou, China.,Research Unit of Evidence-Based Evaluation and Guidelines (2021RU017), Chinese Academy of Medical Sciences, Lanzhou University, Lanzhou, China.,WHO Collaborating Center for Guideline Implementation and Knowledge Translation, Lanzhou, China
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
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6
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Clinical practice guidelines: The good, the bad, and the ugly. Injury 2022:S0020-1383(22)00077-8. [PMID: 35135686 DOI: 10.1016/j.injury.2022.01.047] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/29/2022] [Indexed: 02/02/2023]
Abstract
Clinical practices guidelines (CPGs) play a fundamental role in improving healthcare and patients' outcomes by helping clinicians make the best evidence-based decisions for their patients in a time-efficient manner. By following the available methods and criteria to create trustworthy CPGs, panel members can develop high-quality guidelines. However, despite the improvements over the years, CPGs are still subjected to biases and limitations, with conflicts of interest being the ugliest problem GCPs must face. In this review, we discuss the main characteristics of clinical practice guidelines, their pros and cons, and the future challenges they need to overcome.
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7
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Abstract
Micro- or minimally invasive glaucoma surgeries (MIGS) have been the latest addition to the glaucoma surgical treatment paradigm. This term refers not to a single surgery, but rather to a group of distinct procedures and devices that aim to decrease intraocular pressure. Broadly, MIGS can be categorized into surgeries that increase the trabecular outflow [Trabectome, iStent (first and second generations), Hydrus microstent, Kahook Dual Blade and gonioscopy-assisted transluminal trabeculotomy], surgeries that increase suprachoroidal outflow (Cypass microstent and iStent Supra), and conjunctival bleb-forming procedures (Xen gel stent and InnFocus microshunt). Compared to traditional glaucoma surgeries, such as trabeculectomy and glaucoma drainage device implantation (Ahmed, Baerveldt, and Molteno valves), MIGS are touted to have less severe complications and shorter surgical time. MIGS represent an evolving field, and the efficacy and complications of each procedure should be considered independently, giving more importance to high-quality and longer-term studies.
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Affiliation(s)
- David J Mathew
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario M5T 2S8, Canada;
| | - Yvonne M Buys
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario M5T 2S8, Canada;
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8
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Brems JH, Davis AE, Clayton EW. Analysis of conflict of interest policies among organizations producing clinical practice guidelines. PLoS One 2021; 16:e0249267. [PMID: 33930893 PMCID: PMC8087455 DOI: 10.1371/journal.pone.0249267] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/16/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Conflicts of interest (COI) jeopardize the validity of Clinical Practice Guidelines (CPGs). When the Institute of Medicine promulgated COI policies in 2011, few organizations met these requirements, but it is unknown if organizations have improved their policies since that time. We sought to evaluate current adherence to IOM standards of COI policies. METHODS AND FINDINGS We conducted a retrospective document review of COI policies and CPGs from organizations that published five or more CPGs between January 1, 2018 and December 31, 2019. Organizations were identified via CPG databases. COI policies were obtained from an internet search. We collected data on i) the number of organizations that have COI policies specific to CPG development, ii) the number of policies meeting each IOM standard and iii) the number of IOM standards met by each policy. COI disclosures from five CPGs of each organization were assessed for adherence to IOM standards. Among the 46 organizations that published 5 or more CPGs, 36 (78%) had a COI policy. Standard 2.2b (requiring divestment of financial COI) was met least frequently, by 2 of 36 (6%) organizations. Standard 2.1 (requiring disclosure of COI) was met most frequently, by 33 of 36 (92%) organizations. A total of 31 of 36 (86%) organizations met 4 or fewer of the 7 IOM standards. Among the 16 organizations limiting COI to a minority of the CPG panel (standard 2.4c) and the 15 organizations prohibiting COI among chairs or co-chairs (standard 2.4d), 12 (75%) and 10 (67%) organizations violated the respective standard in at least one CPG. The main limitations of our study are the exclusion of organizations producing fewer CPGs and ability to assess only publicly available policies. CONCLUSION Among organizations producing CPGs, COI policies frequently do not meet IOM standards, and organizations often violate their own policies. These shortcomings may undermine the public trust in and thus the utility of CPGs. CPG-producing organizations should improve their COI policies and their strategies to manage COI to increase the trustworthiness of CPGs.
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Affiliation(s)
- J. Henry Brems
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- * E-mail:
| | - Andrea E. Davis
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Ellen Wright Clayton
- Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Law School, Vanderbilt University, Nashville, Tennessee, United States of America
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9
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Tabatabavakili S, Khan R, Scaffidi MA, Gimpaya N, Lightfoot D, Grover SC. Financial Conflicts of Interest in Clinical Practice Guidelines: A Systematic Review. Mayo Clin Proc Innov Qual Outcomes 2021; 5:466-475. [PMID: 33997642 PMCID: PMC8105509 DOI: 10.1016/j.mayocpiqo.2020.09.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective To systematically evaluate the prevalence of disclosed and undisclosed financial conflicts of interest (FCOI) among clinical practice guidelines (CPGs). Methods In this systematic review, we ascertained the prevalence and types of FCOI for CPGs from January 1, 1980, to March 3, 2019. The primary outcome was the prevalence of FCOI among authors of CPGs. FCOI disclosures were compared between medical subspecialties and societies producing CPGs. Results Among the 37 studies including 14,764 total guideline authors, 45% had at least one FCOI. The prevalence of FCOI per study ranged from 6% to 100%. More authors had FCOI involving general payments (39%) compared with research payments (29%). Oncology, neurology, and gastroenterology had the highest prevalence of FCOI compared with other medical specialties. Among the 8 studies that included the monetary values in US dollars of FCOI, average payments per author ranged from $578 to $242,300. Among the 10 studies that included data on undisclosed FCOI, 32% of authors had undisclosed industry payments. Conclusion There are numerous FCOI among authors of CPGs, many of which are undisclosed. Our study found a significant difference in FCOI prevalence based on types of FCOI and CPG sponsor society. Additional research is required to quantify the implications of FCOI on clinical judgment and patient care. Financial conflicts of interest (FCOI) may have an impact on the objectivity of clinical practice guidelines. Among the 37 studies included in this systematic review, 45% of the 14,764 guideline authors had an FCOI. Authors of oncology, neurology, and gastroenterology guidelines had higher prevalence of FCOI compared with other guidelines. Eight studies included monetary value of FCOI, which ranged from $578 to $242,300 per author. Little is known about the direct impact of FCOI on how authors of clinical practice guidelines vote on recommendations during guideline development.
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Affiliation(s)
- Sahar Tabatabavakili
- Department of Medicine, University of Toronto, Ontario, Canada.,Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Rishad Khan
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Michael A Scaffidi
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada.,Faculty of Health Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Nikko Gimpaya
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - David Lightfoot
- Health Science Library, Unity Health Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Samir C Grover
- Department of Medicine, University of Toronto, Ontario, Canada.,Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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Nejstgaard CH, Bero L, Hróbjartsson A, Jørgensen AW, Jørgensen KJ, Le M, Lundh A. Conflicts of interest in clinical guidelines, advisory committee reports, opinion pieces, and narrative reviews: associations with recommendations. Cochrane Database Syst Rev 2020; 12:MR000040. [PMID: 33289919 PMCID: PMC8092573 DOI: 10.1002/14651858.mr000040.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Treatment and diagnostic recommendations are often made in clinical guidelines, reports from advisory committee meetings, opinion pieces such as editorials, and narrative reviews. Quite often, the authors or members of advisory committees have industry ties or particular specialty interests which may impact on which interventions are recommended. Similarly, clinical guidelines and narrative reviews may be funded by industry sources resulting in conflicts of interest. OBJECTIVES To investigate to what degree financial and non-financial conflicts of interest are associated with favourable recommendations in clinical guidelines, advisory committee reports, opinion pieces, and narrative reviews. SEARCH METHODS We searched PubMed, Embase, and the Cochrane Methodology Register for studies published up to February 2020. We also searched reference lists of included studies, Web of Science for studies citing the included studies, and grey literature sources. SELECTION CRITERIA We included studies comparing the association between conflicts of interest and favourable recommendations of drugs or devices (e.g. recommending a particular drug) in clinical guidelines, advisory committee reports, opinion pieces, or narrative reviews. DATA COLLECTION AND ANALYSIS Two review authors independently included studies, extracted data, and assessed risk of bias. When a meta-analysis was considered meaningful to synthesise our findings, we used random-effects models to estimate risk ratios (RRs) with 95% confidence intervals (CIs), with RR > 1 indicating that documents (e.g. clinical guidelines) with conflicts of interest more often had favourable recommendations. We analysed associations for financial and non-financial conflicts of interest separately, and analysed the four types of documents both separately (pre-planned analyses) and combined (post hoc analysis). MAIN RESULTS We included 21 studies analysing 106 clinical guidelines, 1809 advisory committee reports, 340 opinion pieces, and 497 narrative reviews. We received unpublished data from 11 studies; eight full data sets and three summary data sets. Fifteen studies had a risk of confounding, as they compared documents that may differ in other aspects than conflicts of interest (e.g. documents on different drugs used for different populations). The associations between financial conflicts of interest and favourable recommendations were: clinical guidelines, RR: 1.26, 95% CI: 0.93 to 1.69 (four studies of 86 clinical guidelines); advisory committee reports, RR: 1.20, 95% CI: 0.99 to 1.45 (four studies of 629 advisory committee reports); opinion pieces, RR: 2.62, 95% CI: 0.91 to 7.55 (four studies of 284 opinion pieces); and narrative reviews, RR: 1.20, 95% CI: 0.97 to 1.49 (four studies of 457 narrative reviews). An analysis combining all four document types supported these findings (RR: 1.26, 95% CI: 1.09 to 1.44). One study investigating specialty interests found that the association between including radiologist guideline authors and recommending routine breast cancer screening was RR: 2.10, 95% CI: 0.92 to 4.77 (12 clinical guidelines). AUTHORS' CONCLUSIONS We interpret our findings to indicate that financial conflicts of interest are associated with favourable recommendations of drugs and devices in clinical guidelines, advisory committee reports, opinion pieces, and narrative reviews. However, we also stress risk of confounding in the included studies and the statistical imprecision of individual analyses of each document type. It is not certain whether non-financial conflicts of interest impact on recommendations.
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Affiliation(s)
- Camilla Hansen Nejstgaard
- Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Odense, Denmark
- Nordic Cochrane Centre, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Lisa Bero
- Center for Bioethics and Humanities, University of Colorado, Colorado, USA
| | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | | | | | - Mary Le
- Stasjonsgata Legekontor, Hokksund, Norway
| | - Andreas Lundh
- Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
- Department of Infectious Diseases, Hvidovre Hospital, Hvidovre, Denmark
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11
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Rosoff PM. Healthcare Rationing Cutoffs and Sorites Indeterminacy. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2020; 44:479-506. [PMID: 31356664 DOI: 10.1093/jmp/jhz012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Rationing is an unavoidable mechanism for reining in healthcare costs. It entails establishing cutoff points that distinguish between what is and is not offered or available to patients. When the resource to be distributed is defined by vague and indeterminate terms such as "beneficial," "effective," or even "futile," the ability to draw meaningful boundary lines that are both ethically and medically sound is problematic. In this article, I draw a parallel between the challenges posed by this problem and the ancient Greek philosophical conundrum known as the "sorites paradox." I argue, like the paradox, that the dilemma is unsolvable by conventional means of logical analysis. However, I propose another approach that may offer a practical solution that could be applicable to real-life situations in which cutoffs must be decided (such as rationing).
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Affiliation(s)
- Philip M Rosoff
- Duke University School of Medicine, Durham, North Carolina, USA
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12
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El-Rayess H, Khamis AM, Haddad S, Ghaddara HA, Hakoum M, Ichkhanian Y, Bejjani M, Akl EA. Assessing concordance of financial conflicts of interest disclosures with payments' databases: a systematic survey of the health literature. J Clin Epidemiol 2020; 127:19-28. [PMID: 32622901 DOI: 10.1016/j.jclinepi.2020.06.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 06/21/2020] [Accepted: 06/28/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective of the study is to review the literature for studies that assessed the concordance of financial conflicts of interest disclosures with payments' databases and evaluate their methods. STUDY DESIGN AND SETTING We conducted a systematic survey of the health literature to identify eligible studies. We searched both Medline and EMBASE up to February 2017. We conducted study selection, data abstraction, and methodological quality assessment in duplicate and independently using standardized forms. We subcategorized 'nonconcordant disclosures' as either 'partially nonconcordant' or 'completely nonconcordant'. The main outcome was the percentage of authors with 'nonconcordant' disclosures. We summarized results by three levels of analysis: authors, companies, and studies. RESULTS We identified 27 eligible journal articles. The top two types of documents assessed were published articles (n = 13) and published guidelines (n = 9). The most commonly used payment database was the Open Payments Database (n = 16). The median percentage of authors with 'nonconcordant' disclosures was 81%; the median percentage was 43% for 'completely nonconcordant' disclosures. The percentage of 'nonconcordant' conflict of interest (COI) reporting by companies varied between 23% and 85%. The methods of concordance assessment, as well as the labeling and definitions of assessed outcomes varied widely across the included studies. We judged three of the included studies as high-quality studies. CONCLUSION Underreporting of health science researchers' financial COIs is pervasive. Studies assessing COI underreporting suffer from a number of limitations that could have overestimated their findings.
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Affiliation(s)
- Hebah El-Rayess
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Assem M Khamis
- Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Sara Haddad
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hussein Abou Ghaddara
- Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Maram Hakoum
- Department of Family Medicine, Cornerstone Care Teaching Health Center, Morgantown, WV, USA
| | - Yervant Ichkhanian
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Michael Bejjani
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon; Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon; Faculty of Medicine, American University of Beirut, Beirut, Lebanon; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
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Qaseem A, Wilt TJ, Forciea MA, Kansagara D, Crandall CJ, Fitterman N, Hicks LA, Horwitch CA, Lin JS, Maroto M, McLean RM, Mustafa RA, Roa J, Tufte J, Vijan S. Disclosure of Interests and Management of Conflicts of Interest in Clinical Guidelines and Guidance Statements: Methods From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2019; 171:354-361. [PMID: 31426089 DOI: 10.7326/m18-3279] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
One of the hallmarks of a trustworthy clinical guideline or guidance statement is a comprehensive process for disclosure of interests (DOI) and management of conflicts of interest (COIs). The American College of Physicians (ACP) Clinical Guidelines Committee (CGC) aims to disclose all health care-related interests and manage conflicts in a manner that is transparent, proportional, and consistent. Any person involved in the development of an ACP clinical guideline or guidance statement must disclose all financial and intellectual interests related to health care from the previous 3 years. Persons complete disclosures at the start of their participation and are required to update them over the course of their involvement with the CGC, including before each CGC meeting. A DOI-COI Review and Management Panel reviews the disclosures; flags potential conflicts; grades the COI as low-, moderate-, or high-level; and manages the person's participation accordingly. A high-level COI results in recusal from authorship, voting, and all committee discussions. Participants with a moderate-level COI are recused from authorship and voting for clinically relevant topics but may participate in all discussions. A low-level COI results in no role restrictions. All disclosures and COI management decisions are publicly reported.
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Affiliation(s)
- Amir Qaseem
- American College of Physicians, Philadelphia, Pennsylvania (A.Q.)
| | - Timothy J Wilt
- Minneapolis VA Medical Center, Minneapolis, Minnesota (T.J.W.)
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14
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Conflicts of interest and outcomes of clinical trials of antidepressants: An 18-year retrospective study. J Psychiatr Res 2019; 116:83-87. [PMID: 31212249 DOI: 10.1016/j.jpsychires.2019.05.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 05/24/2019] [Accepted: 05/31/2019] [Indexed: 11/24/2022]
Abstract
Pharmaceutical sponsorship, funding sources, and investigators' conflicts of interest may be potential influencers in the conduct and results of clinical trials, as well as in the promotion of psychiatric drug therapies. We report the results of an audit of randomized controlled trials (RCTs) of antidepressants conducted from 2000 to 2017. We searched the Web of Science databases with a comprehensive search strategy to identify phase 2 and 3 RCTs. Out of the 1085 articles initially located, a total of 291 RCTs were identified and included in the final analyses. A higher percentage of RCTs conducted by employees of pharmaceutical companies reported favorable results than those with academic or governmental funding (76.90% vs. 60.60%); however, this association was not significant (Χ2 = 2.47, P = 0.18). The data were further analyzed using bivariate and cluster analytical approaches, and the nonsignificant association persisted in both cases. However, analyses of industry-funded placebo-controlled trials (a subgroup of the 291 RCTs) revealed a higher proportion of results that were reported as significant compared to their counterparts with other funding sources (67% vs. 33%). This association was statistically significant (Χ2 = 9.56, P = 0.002), indicating that there is evidence in support of conflicts of interest as a potential bias in the outcomes of RCTs conducted for antidepressants.
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15
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Hess CW, Karter J, Cosgrove L, Hayden L. Evidence-based practice: a comparison of International Clinical Practice Guidelines and current research on physical activity for mild to moderate depression. Transl Behav Med 2019; 9:703-710. [PMID: 30321410 DOI: 10.1093/tbm/iby092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In 2016, the U.S. Preventive Services Task Force recommended routine depression screening for individuals aged 13 and above. Questionnaire-based screening will likely increase treatment in patients with milder symptoms. Although professional groups who develop clinical practice guidelines recognize the importance of considering the risks and benefits of interventions, no official mandate exists for a stepped-care approach. Physical activity warrants increased consideration in guidelines, given the optimal risk/benefit profile and the increasing evidence of efficacy for the treatment and prevention of depression. The aim of the current study was to evaluate clinical practice guidelines for the treatment of major depressive disorder, specifically the recommendation of physical activity and adherence to a stepped-care approach. Authors searched three databases to identify treatment guidelines for depression. Guidelines were reviewed on the following domains regarding recommendation of physical activity: (a) front-line intervention, (b) explicit but not front-line recommendation, (c) inexplicit recommendation, (d) no mention, (e) adherence to a stepped-care approach, and (f) presentation of empirical support for their recommendation. Seventeen guidelines met inclusion criteria. Four guidelines recommended physical activity as a front-line intervention, two did not mention physical activity, eleven made some mention of physical activity, seven presented evidence to support their recommendation, and seven employed a stepped-care approach. The majority of guidelines did not use a stepped-care approach and varied greatly in their inclusion of physical activity as a recommended intervention for mild to moderate depression. Implications for practice, research, and policy are discussed.
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Affiliation(s)
- Courtney Wynne Hess
- Department of Counseling & School Psychology, University of Massachusetts, Boston, MA, USA
| | - Justin Karter
- Department of Counseling & School Psychology, University of Massachusetts, Boston, MA, USA
| | - Lisa Cosgrove
- Department of Counseling & School Psychology, University of Massachusetts, Boston, MA, USA
| | - Laura Hayden
- Department of Counseling & School Psychology, University of Massachusetts, Boston, MA, USA
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16
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[Impact of conflicts of interest on guideline recommendations : Empirical study within the second update of the German interdisciplinary S3 guidelines on fibromyalgia syndrome]. Schmerz 2018; 31:308-318. [PMID: 28455823 DOI: 10.1007/s00482-017-0218-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The impact of conflicts of interest (COI) in general and of academic COI in particular on guideline recommendations in pain medicine has not yet been studied. Whether the inclusion of patients and of representatives of all relevant healthcare professions into a guidelines group is protective against a systematic bias of decisions of a guidelines group is currently unknown. METHODS All members of the guidelines group declared their COI before the consensus conferences by a standard form according to the rules and standards of the Association of the German Medical and Scientific Societies. The acceptance or rejection and the strength of consensus of recommendations of the second update of the interdisciplinary guidelines on fibromyalgia syndrome was analyzed twice by first including and then excluding the votes of the guideline group members with COI related to a recommendation from the results of anonymous voting via an internet platform. RESULTS A total of 42 persons from different healthcare professions and patients participated in the online voting on recommendations. Of the participants 29% had no COI according to the predefined criteria, 53% met the criteria of academic and 33% the criteria of financial COI. In the case of exclusion of participants with a COI related to a specific recommendation, 2 out of 23 recommendations (homeopathy, tramadol) were not accepted. In all votes, there were more participants without COI than with COI. CONCLUSION Academic COI were more frequent than financial COI in the second update of the German interdisciplinary guidelines group on fibromyalgia syndrome. The impact of COI on guideline recommendations was low. The inclusion of patients and of all relevant healthcare professionals into a guidelines group is a protective factor against the influence of COI on guideline recommendations.
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Mechanick JI, Pessah-Pollack R, Camacho P, Correa R, Figaro MK, Garber JR, Jasim S, Pantalone KM, Trence D, Upala S. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY PROTOCOL FOR STANDARDIZED PRODUCTION OF CLINICAL PRACTICE GUIDELINES, ALGORITHMS, AND CHECKLISTS - 2017 UPDATE. Endocr Pract 2017; 23:1006-1021. [PMID: 28786720 DOI: 10.4158/ep171866.gl] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Clinical practice guideline (CPG), clinical practice algorithm (CPA), and clinical checklist (CC, collectively CPGAC) development is a high priority of the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE). This 2017 update in CPG development consists of (1) a paradigm change wherein first, environmental scans identify important clinical issues and needs, second, CPA construction focuses on these clinical issues and needs, and third, CPG provide CPA node/edge-specific scientific substantiation and appended CC; (2) inclusion of new technical semantic and numerical descriptors for evidence types, subjective factors, and qualifiers; and (3) incorporation of patient-centered care components such as economics and transcultural adaptations, as well as implementation, validation, and evaluation strategies. This third point highlights the dominating factors of personal finances, governmental influences, and third-party payer dictates on CPGAC implementation, which ultimately impact CPGAC development. The AACE/ACE guidelines for the CPGAC program is a successful and ongoing iterative exercise to optimize endocrine care in a changing and challenging healthcare environment. ABBREVIATIONS AACE = American Association of Clinical Endocrinologists ACC = American College of Cardiology ACE = American College of Endocrinology ASeRT = ACE Scientific Referencing Team BEL = best evidence level CC = clinical checklist CPA = clinical practice algorithm CPG = clinical practice guideline CPGAC = clinical practice guideline, algorithm, and checklist EBM = evidence-based medicine EHR = electronic health record EL = evidence level G4GAC = Guidelines for Guidelines, Algorithms, and Checklists GAC = guidelines, algorithms, and checklists HCP = healthcare professional(s) POEMS = patient-oriented evidence that matters PRCT = prospective randomized controlled trial.
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Schaefer JL, Aubert Bonn N, Craenen G. Declaring Conflict of Interest - Current State of Affairs in the Ophthalmic Literature. Account Res 2017; 24:375-383. [PMID: 28745950 DOI: 10.1080/08989621.2017.1357474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The importance of transparency with financial ties in biomedical research is widely recognized, and most peer-reviewed journals require declarations of Conflicts of Interest (COI). Nonetheless, variability in the consistency of declarations of COI has been sparsely assessed. To assess consistency and rates of COI declarations in the ophthalmic literature and the effectiveness of journal COI policies. We analyzed consistency and completeness of declaration of COI in the ophthalmic literature and compared the levels of completeness to specific journal requirements. Six-hundred forty-two peer reviewed articles satisfied the inclusion criteria. In 64%, COIs were unreported, in 25% declaration of COI was incomplete, and 11% of the articles reviewed had complete declaration of COI. Of the 33 journals in which the most frequently published authors' articles appeared, 10 required the authors to complete the International Committee of Medical Journal Editors (ICMJE) form or an equivalent form, but this did not affect the rates of COI declaration. In a random sampling of the most frequently published authors in the field of ophthalmology, declaration of COI was low and highly inconsistent. Requiring a standardized COI form has no significant effect on the rate of accurate COI reporting. Our findings lend support to the growing body of literature that shows that journals and editors may need to take a more active role in ensuring accurate and consistent COI reporting.
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Affiliation(s)
- Jamie Lea Schaefer
- a Department of Ophthalmology , University at Buffalo Ross Eye Institute , Buffalo , New York , USA
| | - Noemie Aubert Bonn
- b Faculty of Medicine and Life Sciences , Hasselt University , Hasselt , Belgium
| | - Geert Craenen
- a Department of Ophthalmology , University at Buffalo Ross Eye Institute , Buffalo , New York , USA.,c The Romanell Center for Clinical Ethics and Philosophy of Medicine , Western New York VAMC , Buffalo , New York , USA
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