Failure to discount for conflict of interest when evaluating medical literature: a randomised trial of physicians

CONTEXT

Physicians are regularly confronted with research that is funded or presented by industry.

OBJECTIVE

To assess whether physicians discount for conflicts of interest when weighing evidence for prescribing a new drug.

DESIGN AND SETTING

Participants were presented with an abstract from a single clinical trial finding positive results for a fictitious new drug. Physicians were randomly assigned one version of a hypothetical scenario, which varied on conflict of interest: 'presenter conflict', 'researcher conflict' and 'no conflict'.

PARTICIPANTS

515 randomly selected Fellows in the American College of Obstetricians and Gynecologists' Collaborative Ambulatory Research Network; 253 surveys (49%) were returned. MAIN OBJECT MEASURES: The self-reported likelihood that physicians would prescribe the new drug as a first-line therapy.

RESULTS

Physicians do not significantly discount for conflicts of interest in their self-reported likelihood of prescribing the new drug after reading the single abstract and scenario. However, when asked explicitly to compare conflict and no conflict, 69% report that they would discount for researcher conflict and 57% report that they would discount for presenter conflict. When asked to guess how favourable the results of this study were towards the new drug, compared with the other trials published so far, their perceptions were not significantly influenced by conflict of interest information.

CONCLUSION

While physicians believe that they should discount the value of information from conflicted sources, they did not do so in the absence of a direct comparison between two studies. This brings into question the effectiveness of merely disclosing the funding sources of published studies.

Factors associated with physicians' reliance on pharmaceutical sales representatives

PURPOSE

To examine relationships between pharmaceutical representatives and obstetrician-gynecologists and identify factors associated with self-reported reliance on representatives when making prescribing decisions.

METHOD

In 2006-2007, questionnaires were mailed to 515 randomly selected physicians in the American College of Obstetricians and Gynecologists' Collaborative Ambulatory Research Network. Participants were asked about the information sources used when deciding to prescribe a new drug, interactions with sales representatives, views of representatives' value, and guidelines they had read on appropriate industry interactions.

RESULTS

Two hundred fifty-one completed questionnaires (49%) were returned. Seventy-six percent of participants see sales representatives' information as at least somewhat valuable. Twenty-nine percent use representatives often or almost always when deciding whether to prescribe a new drug; 44% use them sometimes. Physicians in private practice are more likely than those in university hospitals to interact with, value, and rely on representatives; community hospital physicians tend to fall in the middle. Gender and age are not associated with industry interaction. Dispensing samples is associated with increased reliance on representatives when making prescribing decisions, beyond what is predicted by a physician's own beliefs about the value of representatives' information. Reading guidelines on physician-industry interaction is not associated with less reliance on representatives after controlling for practice setting.

CONCLUSIONS

Physicians' interactions with industry and their familiarity with guidelines vary by practice setting, perhaps because of more restrictive policies in university settings, professional isolation of private practice, or differences in social norms. Prescribing samples may be associated with physicians' use of information from sales representatives more than is merited by the physicians' own beliefs about the value of pharmaceutical representatives.

What obstetrician-gynecologists think of preconception care

Objectives: To describe obstetrician-gynecolog-ists’ opinions of preconception care (PCC) and ascertain patient uptake for this service. Methods: A questionnaire was mailed to 1105 ACOG members in August 2004. Results: There was a 60% response rate. Most physicians think PCC is important (87%) and almost always recommend it to women planning a pregnancy (94%); 54% do so with women who are sexually active. Around a third (34%) thought their patients usually do not plan their pregnancies and 49% said very few pregnant patients came in for PCC. Of those who obtain PCC, they were believed to do so more likely to assure a healthy pregnancy (83%) than because of an elevated risk for birth defects (20%). Of 11 issues presented, cigarette smoking and folic acid supplementation were rated the most important for PCC counseling; exercise and environmental concerns were the least important. Conclusions: Physicians are willing to provide PCC but few patients are accessing such services.

Cesarean delivery on maternal request: obstetrician-gynecologists' knowledge, perception, and practice patterns

OBJECTIVE

To examine obstetrician-gynecologists' knowledge, opinions, and practice patterns related to cesarean delivery on maternal request.

METHODS

Questionnaires were mailed to 1,031 American College of Obstetricians and Gynecologists Fellows in February 2006, with a response rate of 68%. The questionnaire queried respondents' demographic characteristics, practices and attitudes surrounding vaginal and cesarean deliveries, knowledge and beliefs regarding the risks and benefits of elective and nonelective cesarean delivery, and counseling practices and department policies for cesarean delivery on maternal request.

RESULTS

About half of respondents believe women have the right to cesarean delivery on maternal request, and a similar percentage acknowledge having performed at least one cesarean delivery on maternal request. Fifty-eight percent of respondents note an increase in patient inquiries regarding cesarean delivery over the past year, yet most of their practices do not have a policy regarding this procedure. Respondents attribute the increase in inquiries to the increase of information from the media and to convenience. Respondents cited more risks than benefits of cesarean delivery on maternal request, and nearly all discuss these risks with patients who are considering one. Females were more negative toward cesarean delivery on maternal request than males and endorsed more risks and fewer benefits. There were no relationships between assessment of risks and benefits or practice with clinician age or patient characteristics.

CONCLUSION

Most obstetrician-gynecologists in this study recognized an increased demand for cesarean delivery on maternal request within their practices, while believing that the risks of this procedure outweigh the benefits. Clinicians would benefit from strong evidence regarding risks and benefits, evidence that is crucial to guiding policy making with regard to cesarean delivery on maternal request.

LEVEL OF EVIDENCE

III.

Assessment and Management of Obesity

Obesity is a serious medical condition that significantly impacts the health of pregnant and nonpregnant women. Although obstetrician-gynecologists have reported that they are knowledgeable of the health risks associated with obesity, they have also reported that their knowledge of weight assessment and management is inadequate. The purpose of this article is to review the proper procedures for assessing and managing obesity. By properly assessing obesity and constructing individualized weight management plans for those affected, obstetrician-gynecologists can help reduce the prevalence of obesity in women of childbearing ages.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to explain the impact of obesity on the health of nonpregnant and pregnant women, summarize the methods of distinguishing overweight from obesity, and recall the proper weight management programs for and assessments of obesity in women.

Interactions of doctors with the pharmaceutical industry

OBJECTIVE

To assess the opinions and practice patterns of obstetrician-gynaecologists on acceptance and use of free drug samples and other incentive items from pharmaceutical representatives.

METHODS

A questionnaire was mailed in March 2003 to 397 members of the American College of Obstetricians and Gynecologists who participate in the Collaborative Ambulatory Research Network.

RESULTS

The response rate was 55%. Most respondents thought it proper to accept drug samples (92%), an informational lunch (77%), an anatomical model (75%) or a well-paid consultantship (53%) from pharmaceutical representatives. A third (33%) of the respondents thought that their own decision to prescribe a drug would probably be influenced by accepting drug samples. Respondents were more likely to think the average doctor's prescribing would be influenced by acceptance of the items than theirs would be (p<0.002). Respondents who distributed drug samples to patients indicated doing so because of patients' financial need (94%) and for their convenience (76%) and less so as a result of knowledge of the efficacy of the sample product (63%). A third (34%) of respondents agreed that interactions with industry should be more strictly regulated.

CONCLUSION

Obstetrician-gynaecologists largely indicated that they would act in accordance with what they think is proper regarding accepting incentive items from pharmaceutical representatives. Although accepting free drug samples was considered to be appropriate more often than any other item, samples were most commonly judged to be influential on prescribing practices. The widely accepted practice of receiving and distributing free drug samples needs to be examined more carefully.

A survey of obstetrician-gynecologists concerning practice patterns and attitudes toward hormone therapy

OBJECTIVE

To examine the knowledge and prescribing practices of obstetrician-gynecologists regarding hormone therapy in light of the published evidence from the Women's Health Initiative study on combined estrogen + progestin.

DESIGN

A survey questionnaire was sent to 2,500 randomly selected Fellows of the American College of Obstetricians and Gynecologists in November of 2003; 705 surveys were returned. Of those, 644 reported their specialty as obstetrics and/or gynecology and those responses are reported.

RESULTS

A majority of physicians that completed their residency before 1995, both men and women, were not convinced by the WHI research results and disagreed with the decision to end the trial. Physicians that rated themselves very confident about their ability to interpret the scientific literature were more likely to be unconvinced by the results and to disagree with the decision to end the trial. In general, physicians that completed their residency more recently rated the benefits of hormone therapy lower and the risks higher. A majority of respondents (53.3%) reported that their prescribing practices were unlikely to change; however, 29.6% reported that they would be somewhat less likely and 9.5% dramatically less likely to prescribe hormone therapy. Physicians reported that their patients were less likely to request hormone therapy (91.8%) and were more likely to discontinue use (93.0%).

CONCLUSION

Physicians that have been in practice longer were more positive about the risks and benefits of HT, and were more skeptical about the recent research. The published data seem to have affected patient preferences and to have had some effect on physician prescribing practices.

Clinical Approach to Mental Health Issues Among Obstetrician???Gynecologists: A Review

In recent years, obstetrician-gynecologists have taken on a greater role in the provision of primary care. Mental health has been a topic worthy of further exploration as a result of the high prevalence rates of women presenting in gynecologic settings with depressive, anxiety, or eating-disordered symptoms. The detrimental effects of psychopathology have been well documented in the literature, especially if present during pregnancy. This article provides a review of the literature in the area of clinical practice related to mental health among obstetrician-gynecologists based on searches of the Psyc Info and MEDLINE databases. Lack of recognition and underdiagnosis are common problems that need to be addressed by focused educational initiatives.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall the importance of screening for various types of mental disease during an ob/gyn visit; describe the detrimental effects of psychopathology, especially during pregnancy; and explain the importance of educational initiatives in detecting and treating mental disorders.

Neonatal encephalopathy and cerebral palsy revisited: the current state of knowledge and the impact of american college of obstetricians and gynecologists task force report

OBJECTIVES

To re-assess obstetrician-gynecologists' knowledge of neonatal encephalopathy and cerebral palsy after publication of the ACOG/AAP Task Force report.

STUDY DESIGN

A questionnaire investigating knowledge of neonatal encephalopathy and cerebral palsy was mailed to 1060 members of ACOG, 337 of whom participated in a similar study in 2001.

RESULTS

There was a strong association between familiarity with ACOG documentation and knowledge of neonatal encephalopathy (NE) and cerebral palsy (CP) (p<0.001). As with obstetricians surveyed in 2001, knowledge gaps remain. Performance was better on practices questions than knowledge questions. About one-third (34.2%) of the physicians said their knowledge of neonatal encephalopathy was poor or deficient; the majority (76%) rated their residency training as inadequate to marginal.

CONCLUSION

The results indicate better knowledge of neonatal encephalopathy and cerebral palsy among physicians more familiar with the Task Force report. There is a clear need for emphasis on these topics during training and continuing medical education.

Impact of Self-Reported Familiarity With Guidelines for Cystic Fibrosis Carrier Screening

OBJECTIVE

To assess the impact of self-reported familiarity with published guidelines on knowledge, implementation, and opinions of obstetrician-gynecologists regarding carrier screening for cystic fibrosis.

METHODS

A questionnaire pertaining to cystic fibrosis screening guidelines was mailed to 1,165 members of the American College of Obstetricians and Gynecologists.

RESULTS

Sixty-four percent of questionnaires were returned. Statistical analyses were limited to the 632 respondents whose primary medical specialty was gynecology (GynOnly) or obstetrics and gynecology (ObGyns). More ObGyns had thoroughly read or skimmed the guidelines (67.1%) than had GynOnlys (41.6%). Correctly responding to basic questions regarding cystic fibrosis was associated with having read the guidelines, although responding to a more complex question was not. Familiarity with the guidelines was associated with correctly identifying the recommendations for offering screening, with practice implementation of cystic fibrosis screening, and with self-ratings of qualifications and training to offer screening and to provide counseling. In contrast, familiarity with the guidelines was not associated with ObGyn's opinion that burden of disease is likely to be influential in patient acceptance of screening. Physicians who had thoroughly read the guidelines were more likely to disagree that the cystic fibrosis screening test is too inaccurate to risk influencing reproductive decision making (thoroughly read = 79% disagree, skimmed = 69%, not read = 58%, not heard of it = 50%).

CONCLUSION

There was a strong association between self-reported familiarity with the American College of Obstetricians and Gynecologists/American College of Medical Genetics guidelines and physicians' knowledge, implementation, and ratings of training for offering cystic fibrosis carrier screening.

Vaginal birth after cesarean delivery: practice patterns of obstetrician-gynecologists

OBJECTIVE

To assess obstetrician-gynecologists' current practice patterns and opinions regarding vaginal birth after cesarean delivery (VBAC).

STUDY DESIGN

Questionnaires were mailed to a random sample of 1,200 American College of Obstetricians and Gynecologists (ACOG) fellows in July 2003. Information was gathered on percentage of cesarean and VBAC deliveries performed, factors influencing changes in these rates in the past 5 years, hospital protocol regarding VBAC and factors influencing the recommendation of VBAC.

RESULTS

Fifty-three percent of questionnaires were returned to ACOG after 3 mailings. Approximately 49% of respondents reported that they were performing more cesarean deliveries than they were 5 years earlier. The primary reasons for this increase were the risk of liability and patient preference for delivery method. More than 25% of physicians reported that they practiced in hospitals that do not follow the ACOG guidelines with respect to resources and immediate availability. Almost all (98.2%) respondents agreed that they knew the risks and benefits of VBAC. However, only 61% reported feeling competent in determining which patients will have a successful VBAC.

CONCLUSION

Obstetrician-gynecologists seem to be aware of the risks and benefits of VBAC; however, there is some doubt as to who should be offered a trial of labor and what predicts a successful VBAC.

Contemporary clinical issues in outpatient obstetrics and gynecology: findings of the Collaborative Ambulatory Research Network, 2001-2004: part II

Obstetrician/gynecologists are taking on more primary care responsibilities and thus are expected to have a wider base of medical knowledge on a variety of women's health issues. The Collaborative Ambulatory Research Network (CARN) was created in 1990 to investigate issues pertinent to women's health and to the practice of obstetrics and gynecology in the outpatient setting. This article summarizes the findings of CARN studies from 2001 to 2004, covering topics of abnormal pregnancy outcomes, complications of pregnancy, and psychologic disorders. Each study provides a glimpse into the current practice patterns, attitudes, and knowledge of the practicing obstetrician/gynecologist. Although aggregate results suggest that clinicians are consistent and knowledgeable in traditional areas of practice, there appears to be a need for comprehensive educational programs to increase clinicians' comfort level with and knowledge of many primary care issues.

Contemporary Clinical Issues in Outpatient Obstetrics and Gynecology: Findings of the Collaborative Ambulatory Research Network, 2001–2004: Part I

Obstetrician/gynecologists are taking on more primary care responsibilities and thus are expected to have a wider base of medical knowledge on a variety of women's health issues. The Collaborative Ambulatory Research Network (CARN) was created in 1990 to investigate issues pertinent to women's health and to the practice of obstetrics and gynecology in the outpatient setting. This article summarizes the findings of CARN studies from 2001 to 2004, covering topics of infectious diseases, cancer screening, and metabolism and nutrition. Each study provides a glimpse into the current practice patterns, attitudes, and knowledge of the practicing obstetrician/gynecologist. Although aggregate results suggest that clinicians are consistent and knowledgeable in traditional areas of practice, there appears to be a need for comprehensive educational programs to increase clinicians' comfort level with and knowledge of many contemporary primary care issues.

Cervical cytology screening practices among obstetrician-gynecologists

OBJECTIVE

To estimate the current cervical cytology screening practices of American College of Obstetricians and Gynecologists (ACOG) Fellows, to establish a baseline for tracking future changes in practice.

METHODS

Questionnaires were mailed to a random sample of ACOG Fellows (n = 599) and to a group of Fellows who have regularly participated in past ACOG surveys (n = 409). The questionnaires asked about current cytology screening and evaluation practices and presented clinical practice vignettes with additional questions. Descriptive statistical methods were used to evaluate the responses.

RESULTS

Questionnaires were returned by 651 physicians (64.6%); 624 were complete. More than 94% of the respondents start cytology testing at age 18 years. Almost three fourths (74.2%) continue screening indefinitely. More than 80% use a liquid-based method of collection. Almost two thirds (65.1%) order human papillomavirus testing occasionally, usually (81.9%) for reports of atypical squamous cells of undetermined significance (ASCUS). Most Fellows in the sample perform colposcopy for an ASCUS result. Reports of atypical glandular cells resulted in variable approaches to further evaluation. Patient age and history were important variables for all test reports. Legal concerns were mentioned as important determinants of practice patterns.

CONCLUSION

In this sample of ACOG Fellows, most perform cervical cytology and evaluate abnormal results in accord with guidelines in place before the recommended changes in screening and evaluation were published in 2003.

Neonatal encephalopathy and cerebral palsy: a knowledge survey of Fellows of The American College of Obstetricians and Gynecologists

OBJECTIVE

To assess practicing obstetricians' knowledge of the etiology and pathophysiology of neonatal encephalopathy and its relationship to cerebral palsy.

METHODS

A questionnaire designed to test both knowledge and practice patterns was mailed to 413 members of the Collaborative Ambulatory Research Network of The American College of Obstetricians and Gynecologists (ACOG), as well as 600 randomly selected non-Network ACOG Fellows. The questionnaire was composed of 15 knowledge questions and three clinical scenarios containing seven knowledge questions. Six of the questions directly assessed knowledge of cerebral palsy.

RESULTS

Of those who returned the questionnaire, 351 practiced obstetrics and were included in the statistical analyses. For the majority of questions, "Don't know" was the most frequent response. The next most frequent response for 8/13 questions was the correct answer. Performance was strongest as regarded actual clinical practice and relatively weak regarding the antecedents of neonatal encephalopathy and cerebral palsy. The physicians' actual knowledge scores showed a significant correlation with their self-assessments of knowledge (r =.41, P <.001). The majority of physicians rated their training on this topic in medical school, residency, and through continuing medical education as marginal or inadequate.

CONCLUSION

The results of this survey identified large knowledge gaps in this area, suggesting a need to develop educational projects to address these deficits by both professional organizations and individual teachers.

Clinical practice guidelines as educational tools for obstetrician-gynecologists

OBJECTIVE

To examine the awareness of and attitudes toward clinical practice guidelines (CPGs) produced by the American College of Obstetricians and Gynecologists (ACOG) among its fellows and to identify factors that would enhance the perceived value of the CPGs.

STUDY DESIGN

A questionnaire survey on clinical practice guidelines sent to 1,000 practicing fellows of ACOG.

RESULTS

Four hundred sixty-two fellows (46.2%) responded. Virtually all (98%) were aware of ACOG CPGs; 61% stated that an ACOG CPG had changed their practice. Far fewer (6-56%) were aware of CPGs from other organizations; 71.9% were aware of all eight ACOG CPGs that were added in 2000 (range, 83.3-90%). Important factors that would enhance the value of CPGs to the respondents were CPGs that were up to date, had demonstrated improved outcomes, were evidence based and were produced by ACOG. Barriers to use were CPGs without summaries, CPGs not specific to the fellows' settings, CPGs not taking patient cost into account and patient requests for different procedures.

CONCLUSION

The widespread awareness by ACOG fellows of CPGs produced by ACOG demonstrates the potential importance of specialty societies in disseminating CPGs. The data suggest that important characteristics of CPGs are being up to date, being evidence based, containing a summary and providing patient education materials.

Intravenous nitroglycerin for uterine relaxation of an inverted uterus

Intravenous nitroglycerin has recently come to the attention of obstetricians as a potent uterine relaxant. In the case presented, it was used to permit replacement of a tightly contracted, inverted uterus. Relaxation was rapid, effective, and associated with no adverse side effects.

alpha-Thalassemia hydrops fetalis: clinical and ultrasonographic considerations

Five pregnant Southeast Asian women presenting during a 14-month period with microcytic anemia, preeclampsia, and size-date discrepancies were all ultimately diagnosed as carrying fetuses with homozygous alpha-thalassemia hydrops fetalis. The perinatal complications of this hemoglobin disorder are unique to persons of this ethnic background and include uniform fatality for the affected infant, maternal preeclamptic morbidity, and retained placenta. In this report the obstetric ultrasound findings are presented and the clinical manifestations are discussed, with recommendations made to reduce this emerging public health problem in the United States.