Financial ties as part of informed consent to postmarketing research. Attitudes of American doctors and patients

Physician–Medical Manufacturing Industry Relationships: Perceptions of Malaysians

The relations between physicians and the medical manufacturing industry(MMI) which includes pharmaceutical, medical device or implants or life science industry, etc., are well known. To promote better physician–patient relationship and to safeguard patients’ interest, it has been proposed to make physician–industry financial relations transparent and accessible to public. This study aimed to explore Malaysian public’s perceptions towards these relationships.

A survey questionnaire was specifically prepared to meet the objective of the study after a review of the existing literature. Statements describing various types of physician–industry financial interactions were formulated based on previous research. The participants were instructed to mark their response to each statement based on a 5-point Likert scale ranging from strongly disagree to strongly agree.

More than half (57.1%) of the participants were aware of the relationships between physicians and MMI and online database was noted to be the most preferred type of disclosure. Age, gender, race, education status, annual income and subjective health influenced the perceptions. Since consumers (patients) are the key stakeholders of the healthcare industry, their opinions are important. It is hoped that disclosing the financial relationships will help them to make a better-informed decision while choosing their healthcare provider.

Knowledge, Beliefs and Attitudes of Patients and the General Public towards the Interactions of Physicians with the Pharmaceutical and the Device Industry: A Systematic Review

OBJECTIVE

To systematically review the evidence on the knowledge, beliefs, and attitudes of patients and the general public towards the interactions of physicians with the pharmaceutical and the device industry.

METHODS

We included quantitative and qualitative studies addressing any type of interactions between physicians and the industry. We searched MEDLINE and EMBASE in August 2015. Two reviewers independently completed data selection, data extraction and assessment of methodological features. We summarized the findings narratively stratified by type of interaction, outcome and country.

RESULTS

Of the 11,902 identified citations, 20 studies met the eligibility criteria. Many studies failed to meet safeguards for protecting from bias. In studies focusing on physicians and the pharmaceutical industry, the percentages of participants reporting awareness was higher for office-use gifts relative to personal gifts. Also, participants were more accepting of educational and office-use gifts compared to personal gifts. The findings were heterogeneous for the perceived effects of physician-industry interactions on prescribing behavior, quality and cost of care. Generally, participants supported physicians' disclosure of interactions through easy-to-read printed documents and verbally. In studies focusing on surgeons and device manufacturers, the majority of patients felt their care would improve or not be affected if surgeons interacted with the device industry. Also, they felt surgeons would make the best choices for their health, regardless of financial relationship with the industry. Participants generally supported regulation of surgeon-industry interactions, preferably through professional rather than governmental bodies.

CONCLUSION

The awareness of participants was low for physicians' receipt of personal gifts. Participants also reported greater acceptability and fewer perceived influence for office-use gifts compared to personal gifts. Overall, there appears to be lower awareness, less concern and more acceptance of surgeon-device industry interactions relative to physician-pharmaceutical industry interactions. We discuss the implications of the findings at the patient, provider, organizational, and systems level.

Public perceptions of physician - pharmaceutical industry interactions: a systematic review

BACKGROUND

Interactions between physicians and the pharmaceutical industry have led to concerns about conflict of interest (COI), resulting in COI guidelines that suggest a threshold beyond which interactions may be considered unacceptable. Guidelines have also outlined the importance of public opinion on the topic. Consequently, we conducted a systematic review to determine the Canadian public's opinions of physician-pharmaceutical industry interactions.

METHODS

A systematic review of the standard health sciences literature as well as grey literature was conducted and a number of experts were contacted. Pre-determined eligibility criteria were used to identify appropriate studies. Meta-analysis of the study findings was not possible owing to the variety of methods of reporting outcomes, the types of interactions studied and the diversity of populations studied.

RESULTS

No studies on Canadian opinions were identified. Ten international studies (n=13,637), seven with patient groups and three with public citizens, were identified that examined opinions on aspects of awareness, acceptability, disclosure and perceived effects of physician-pharmaceutical industry interactions. Heterogeneity was observed in the awareness, acceptability and perceived effects of physician-pharmaceutical industry interactions; however, there appeared to be greater acceptability and fewer perceived effects with smaller, less costly interactions that directly benefit patients or a medical practice. Desire for disclosure of these interactions was consistent across studies.

INTERPRETATION

Research on the public's perception of physician-pharmaceutical industry interactions has been inadequate internationally and non-existent in Canada, and is urgently needed to help shape policies regarding potential conflict of interest.

Financial disclosure and clinical research: what is important to participants?

OBJECTIVE

To assess what participants in company-sponsored clinical trials wish to know about financial aspects of the study.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional questionnaire administered to 324 participants in six clinical trials conducted at the Royal Melbourne Hospital in 1999-2000 and 2006 for non-acute conditions (asthma, chronic obstructive pulmonary disease, osteoporosis, rheumatoid arthritis, diabetes and influenza vaccine efficacy).

MAIN OUTCOME MEASURES

Participants' desire for information on study funding, investigators' conflicts of interest, and use of accrued funds.

RESULTS

259 participants (80%) completed the survey. Participants wanted to be informed about the identity of the project sponsor (148 participants; 57%), whether the investigators owned shares in the company (105; 41%) or received travel grants (83; 32%), how much funding was accrued at study completion (88; 34%), how accrued funds were used (98; 38%), and who approved their use (91; 35%). After adjusting for year of survey and level of education, younger subjects (aged <or= 60 years) wished to be informed more often than older participants of who sponsored the project (odds ratio [OR], 2.35 [95% CI, 1.21-4.55]; P=0.012), whether the investigators owned shares in the company (OR, 2.41 [95% CI, 1.27-4.60]; P=0.007) and how much funding was available for other uses (OR, 1.79 [95% CI, 0.94-3.41]; P=0.078).

CONCLUSION

While most participants indicated that they would take part in clinical research again regardless of whether they received financial information, providing information on the sponsor, the investigators' financial interest in the company, whether accrual of funds is expected, and how these funds will be spent should satisfy the interests of participants in company-sponsored clinical trials.

Patients' views on financial conflicts of interest in cancer research trials

BACKGROUND

Financial ties between researchers or medical centers and companies whose drugs are being tested have come under increasing scrutiny.

METHODS

We conducted in-person interviews with 253 patients in cancer-research trials (a 93% response rate) at five U.S. medical centers to determine their attitudes regarding potential financial conflicts of interest among researchers and medical centers.

RESULTS

More than 90% of patients expressed little or no worry about financial ties that researchers or institutions might have with drug companies. Most patients said they would have enrolled in the trial even if the drug company had paid the researcher for speaking (82% of those interviewed) or consulting (75%) or if the researcher had received royalty payments (70%) or owned stock in the company (76%). Similarly, most patients would have enrolled in the trial if their cancer center had owned stock in the drug company (77%) or received royalty payments from the company (79%). Most patients believed it was ethical for researchers to receive speaking fees (81%) or consulting fees (82%) from the company. However, a substantial minority of patients wanted disclosure of the oversight system for researchers (40%) and of researchers' financial interests (31%); 17% thought no disclosure to patients was necessary.

CONCLUSIONS

Most patients in cancer-research trials were not worried about financial ties between researchers or medical centers and drug companies and would still have enrolled in the trial if they had known about such financial ties. A substantial minority wanted to be informed about the oversight system to protect against financial conflicts of interest and about researchers' financial interests.

The limits of disclosure: what research subjects want to know about investigator financial interests

Research participants' views about investigator financial interests were explored. Reactions ranged from concern to acceptance, indifference, and even encouragement. Although most wanted such information, some said it did not matter, was private, or was burdensome, and other factors were more important to research decisions. Very few said it would affect their research decisions, and many assumed that institutions managed potential conflicts of interest. Although disclosure of investigator financial interest information to research participants is often recommended, its usefulness is limited, especially when participation is desired because of illness.

Attitudes of academic and clinical researchers toward financial ties in research: a systematic review

Involvement of industry in academic research is widespread and associated with favorable outcomes for industry. The objective of this study was to review empirical data on the attitudes of researchers toward industry involvement and financial ties in research. A review of the literature for quantitative data from surveys on the attitudes of researchers to financial ties in research, reported in English, resulted in the 17 studies included. Review of these studies revealed that investigators are concerned about the impact of financial ties on choice of research topic, research conduct and publication, but this concern is less among investigators already involved with industry. Researchers approve of industry collaboration and financial ties when the ties are indirectly related to the research, disclosure is upfront, and results and ideas are freely publicized. However, their trust in disclosure as a way to manage conflicts may reveal a lack of awareness of the actual impact of financial incentives on themselves and other researchers.

Potential research participants' views regarding researcher and institutional financial conflicts of interest

BACKGROUND

Financial conflict of interest in clinical research is an area of active debate. While data exist on the perspectives and roles of academic institutions, investigators, industry sponsors, and scientific journals, little is known about the perspectives of potential research participants.

METHODS

The authors surveyed potential research participants over the internet, using the Harris Interactive Chronic Illness Database. A potential research participant was defined by: (1) self report of diagnosis by a health care professional and (2) willingness to participate in clinical trials. Email invitations were sent to 20 205 persons with coronary artery disease, breast cancer, or depression; a total of 6363 persons were screened; of these, 86% or 5478 met inclusion criteria and completed the survey. The outcome measures were respondents' ratings on: importance of knowing conflict of interest information, whether its disclosure ought to be required, and its effect on willingness to participate-across seven widely discussed scenarios of financial conflicts of interest (ranging from commercial funding to equity ownership).

RESULTS

Majority responded that knowing conflict of interest information was "extremely" or "very" important; a larger majority felt financial conflicts of interest should be disclosed as part of informed consent (64% to 87%). In all seven scenarios, a majority was still willing to participate but in some scenarios a sizable minority would be wary of participation. Respondents were more wary of individual than institutional conflicts of interest. Illness group and sociodemographic factors had modest effects and did not affect the main trends.

CONCLUSIONS

The prevailing practice of non-disclosure of financial conflicts of interest in clinical research appears contrary to the values of potential research participants.

What do we really know about conflicts of interest in biomedical research?

RATIONALE

Conflicts of interest in research have long been seen to pose serious threats to the integrity of research. Indeed, the past two decades have revealed increased attention to the possible influence of conflicts of interest as the number of research studies funded by private industry have increased.

OBJECTIVES

We review empirical findings directly pertinent to issues concerning financial conflicts of interest in biomedical research, and we provide an overview of the current issues and state of understanding concerning such conflicts in research.

METHODS

We searched Medline from January 1992 to January 2002 to locate current studies that have reported primary or secondary empirical data pertaining to conflicts of interest in research.

RESULTS

The rate of potential conflicts of interest for researchers appears to be at least 30% in some situations although the accuracy of such a rate is untested, and the rate of disclosure of conflicts of interest is as low as 2%. Furthermore, some evidence exists to indicate that researchers with conflicting interests may indeed offer different professional opinions and judgments than those for whom such conflicts do not exist. The effectiveness of various disclosure and management methods for conflicts of interest is unknown.

CONCLUSIONS

We summarize the current empirical literature, concluding that relatively little is known based on such data. We suggest a number of questions that need to be answered by future research, and we offer recommendations for policy makers to consider and evaluate in the future in identifying, revealing, and managing conflicts of interest.

Randomized, controlled trials in surgery: perceived barriers and attitudes of Australian colorectal surgeons

PURPOSE

Although the randomized, controlled trial has gained preeminence as the criterion standard for evaluating pharmaceutical treatments, randomized controlled trials in surgery have been perceived as difficult to surmount. Furthermore, attitudes of surgeons toward randomized, controlled trials are not well understood. We determined the views of Australian surgeons about feasibility of and barriers to surgical randomized trials.

METHODS

All members of the Section of Colon and Rectal Surgery of the Royal Australasian College of Surgeons (n = 147) and all Australian colorectal subspecialist surgeons (n = 72) were mailed a questionnaire that included questions about surgical randomized, controlled trials.

RESULTS

A total of 195 surgeons responded (89 percent). Two-thirds (66.7 percent; 95 percent confidence interval 59.5-73.1) of respondents agreed that "Randomized controlled trials should be the study design of choice" to evaluate new surgical procedures. Only 19 percent (95 percent confidence interval 13.9-25.3) endorsed the statement that "too much emphasis is placed on results of randomized controlled trials." Barriers to conducting surgical randomized, controlled trials identified by the majority included insufficient funding (74.4 percent; 95 percent confidence interval 67.5-80.2), a lack of support from the wider surgical community (55.9 percent; 95 percent confidence interval 48.6-62.9), and difficulties in convincing patients to accept random allocation to treatment (62.6 percent; 95 percent confidence interval 55.3-69.3).

CONCLUSION

These results reveal positive attitudes among Australian surgeons toward randomized, controlled trials, although concerns about the feasibility of randomized, controlled trials have been reinforced.

Fraud and Abuse: A Pain Physician's Guide

The growing burden of regulations and statutes that physicians in the United States must comply with has become an inescapable aspect of the practice of medicine. With the advent of this heightened regulation has also come a new governmental commitment to discover and punish fraud and abuse in the practice of medicine. It is thus incumbent upon pain practitioners to be aware of the basic principles in fraud and abuse law so as to avoid obvious situations of legal liability and to know when to seek expert legal advice in the structuring of business transactions affecting their practice.

Barriers to participation in randomized clinical trials for early breast cancer among Australian cancer specialists

BACKGROUND

Doctors' discomfort with the randomized trial process may significantly impact on accrual rates to clinical trials. However, there is little information regarding factors that influence accrual to clinical trials in Australia. The present study examines Australian cancer specialists' attitudes towards and participation in current breast cancer clinical trials.

METHODS

All medical and radiation oncologists across Australia and surgeons listed as participants in the Australian and New Zealand Breast Cancer Trials Group were sent questionnaires assessing attitudes towards and participation in current clinical trials for early stage breast cancer.

RESULTS

The response rate was 71% (269/381). The mean age of respondents was 45 years and 85% were male. Respondents estimated that a mean of 5.2 (SD = 8.2) of their patients had been enrolled in a breast cancer clinical trial in the previous 12 months. Participation (in any trial) by medical oncologists (60.6%, 95% CI 54.5-66.7%) and surgeons (63.1%, 95% CI 57.1-69.1%) was significantly higher than for radiation oncologists (43.2%, 95% CI 37-49.4%, P = 0.03). The major barriers to participation in current breast cancer trials were lack of resources (44%) or issues related to specific trials (44%; e.g. relevance of the research questions or choice of standard therapies).

CONCLUSIONS

The results of this study suggest that efforts to improve doctors' participation in clinical trials need to address a number of issues. More empirical research is needed to evaluate new strategies to raise participation in clinical trials.

Ethical considerations of industry-sponsored research: the use of human subjects

This paper reviews the history and character of these research requirements, with special emphasis on questions concerning the role of industry in sponsored research. This discussion is becoming more vigorous with each passing year as private investment in research assumes greater importance in the scientific enterprise. I concentrate on issues of industry-supported human use that are on the "cutting edge" of contemporary biomedical ethics. Of special interest are questions about the disclosure of financial arrangements between industry and investigators, such as the nature and amount of capitated remuneration.