Financial relationships between patient and consumer representatives and the health industry: A systematic review

Comparison between the for-profit human milk industry and nonprofit human milk banking: Time for regulation?

Human milk (HM) is a highly evolutionary selected, complex biofluid, which provides tailored nutrition, immune system support and developmental cues that are unique to each maternal-infant dyad. In the absence of maternal milk, the World Health Organisation recommends vulnerable infants should be fed with screened donor HM (DHM) from a HM bank (HMB) ideally embedded in local or regional lactation support services. However, demand for HM products has arisen from an increasing awareness of the developmental and health impacts of the early introduction of formula and a lack of prioritisation into government-funded and nonprofit milk banking and innovation. This survey of global nonprofit milk bank leaders aimed to outline the trends, commonalities and differences between nonprofit and for-profit HM banking, examine strategies regarding the marketing and placement of products to hospital and public customers and outline the key social, ethical and human rights concerns. The survey captured information from 59 milk bank leaders in 30 countries from every populated continent. In total, five companies are currently trading HM products with several early-stage private milk companies (PMCs). Products tended to be more expensive from PMC than HMB, milk providers were financially remunerated and lactation support for milk providers and recipients was not a core function of PMCs. Current regulatory frameworks for HM vary widely, with the majority of countries lacking any framework, and most others placing HM within food legislation, which does not include the support and care of milk donors and recipient prioritisation. Regulation as a Medical Product of Human Origin was only in place to prevent the sale of HM in four countries; export and import of HM was banned in two countries. This paper discusses the safety and ethical concerns raised by the commodification of HM and the opportunities policymakers have globally and country-level to limit the potential for exploitation and the undermining of breastfeeding.

The Commercial Determinants of Health and Evidence Synthesis (CODES): methodological guidance for systematic reviews and other evidence syntheses

BACKGROUND

The field of the commercial determinants of health (CDOH) refers to the commercial products, pathways and practices that may affect health. The field is growing rapidly, as evidenced by the WHO programme on the economic and commercial determinants of health and a rise in researcher and funder interest. Systematic reviews (SRs) and evidence synthesis more generally will be crucial tools in the evolution of CDOH as a field. Such reviews can draw on existing methodological guidance, though there are areas where existing methods are likely to differ, and there is no overarching guidance on the conduct of CDOH-focussed systematic reviews, or guidance on the specific methodological and conceptual challenges.

METHODS/RESULTS

CODES provides guidance on the conduct of systematic reviews focussed on CDOH, from shaping the review question with input from stakeholders, to disseminating the review. Existing guidance was used to identify key stages and to provide a structure for the guidance. The writing group included experience in systematic reviews and other forms of evidence synthesis, and in equity and CDOH research (both primary research and systematic reviews).

CONCLUSIONS

This guidance highlights the special methodological and other considerations for CDOH reviews, including equity considerations, and pointers to areas for future methodological and guideline development. It should contribute to the reliability and utility of CDOH reviews and help stimulate the production of reviews in this growing field.

Does patient and public involvement impact public health decision-making? A 10 year retrospective analysis of public consultation in Brazil

BACKGROUND

 The aim of this work is to characterize the processes associated with patient and public involvement (PPI) in the form of public consultations (PC) during the first 10 years of operation of the National Committee for Health Technology Incorporation in the Unified Health System (Conitec) of Brazil, and to identify factors associated with changes in Conitec's recommendations following these PC.

METHODS

 This cross-sectional study analysed all processes related to the adoption of technologies that took place in Brazil between 2012 and 2021 based on technical reports and self-reported information collected from PC participants. A multiple logistic regression model identified factors associated with changes in Conitec's recommendations following PC.

RESULTS

 A total of 479 technical reports were published, of which 83% (n = 400) were submitted to PC. Demands were made mainly by applicants from the government (n = 262; 55%), regarding the adoption of medicines (n = 366; 76%), in which context neoplasms and infectious diseases were the most frequent indications (n = 66; 14% for each). A total of 264 (55%) processes resulted in a final recommendation in favour of introducing the technology. Over the period of 10 years, 196 483 contributions were received in response to PC. The largest volume of contributions was made by patients and their families or representatives (n = 99 082; 50%), females (122 895; 67%), white individuals (129 165; 71%) and individuals between the ages of 25 and 59 years (145 364; 80%). Alteration of the preliminary recommendation occurred in 13% (n = 53) of the PC, with a higher proportion of recommendations being altered from 2017 onwards. Increased participation by patients had a significant impact on the alteration of the preliminary recommendation (odds ratio 3.87, 95% CI 1.33-13.35, p = 0.02).

CONCLUSIONS

Increased engagement of patients and their families and caregivers in PC was associated with changing the preliminary recommendation of Conitec about the adoption of technologies into the public health system in Brazil.

Pharmaceutical policies: effects of policies regulating drug marketing

BACKGROUND

The costs of developing new treatments and bringing them to the market are substantial. The pharmaceutical industry uses drug promotion to gain a competitive market share, and drive sale volumes and industry profitability. This involves disseminating information about new treatments to relevant targets. However, conflicts of interest can arise when profits are prioritised over patient care and its benefits. Drug promotion regulations are complex interventions that aim to prevent potential harm associated with these activities.

OBJECTIVES

To assess the effects of policies that regulate drug promotion on drug utilisation, coverage or access, healthcare utilisation, patient outcomes, adverse events and costs.

SEARCH METHODS

We searched Epistemonikos for related reviews and their included studies. To find primary studies we searched MEDLINE, CENTRAL, Embase, EconLit, Global Index Medicus, Virtual Health Library, INRUD Bibliography, two trial registries and two sources of grey literature. All databases and sources were searched in January 2023.

SELECTION CRITERIA

We planned to include studies that assessed policies regulating drug promotion to consumers, healthcare professionals or regulators and third-party payers, or any combination of these groups.In this review we defined policies as laws, rules, guidelines, codes of practice, and financial or administrative orders made by governments, non-government organisations or private insurers. One of the following outcomes had to be reported: drug utilisation, coverage or access, healthcare utilisation, patient health outcomes, any adverse effects (unintended consequences), and costs. The study had to be a randomised or non-randomised trial, an interrupted time series analysis (ITS), a repeated measures (RM) study or a controlled before-after (CBA) study.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed eligibility for inclusion of studies. When consensus was not reached, any disagreements were discussed with a third review author.  We planned to use the criteria suggested by Cochrane Effective Practice and Organisation of Care (EPOC) to assess the risk of bias of included studies. For randomised trials, non-randomised trials, and CBA studies, we planned to estimate relative effects, with 95% confidence intervals (CI). For dichotomous outcomes, we planned to report the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For ITS and RM, we planned to compute changes along two dimensions: change in level and change in slope. We planned to undertake a structured synthesis following EPOC guidance.  MAIN RESULTS: The search yielded 4593 citations, and 13 studies were selected for full-text review. No study met the inclusion criteria.

AUTHORS' CONCLUSIONS

We sought to assess the effects of policies that regulate drug promotion on drug use, coverage or access, use of health services, patient outcomes, adverse events, and costs, however we did not find studies that met the review's inclusion criteria. As pharmaceutical policies that regulate drug promotion have untested effects, their impact, as well as their positive and negative influences, is currently only a matter of opinion, debate, informal or descriptive reporting. There is an urgent need to assess the effects of pharmaceutical policies that regulate drug promotion using well-conducted studies with high methodological rigour.

Key issues for stakeholder engagement in the development of health and healthcare guidelines

Established in 2015, the Multi-Stakeholder Engagement (MuSE) Consortium is an international network of over 120 individuals interested in stakeholder engagement in research and guidelines. The MuSE group is developing guidance for stakeholder engagement in the development of health and healthcare guideline development. The development of this guidance has included multiple meetings with stakeholders, including patients, payers/purchasers of health services, peer review editors, policymakers, program managers, providers, principal investigators, product makers, the public, and purchasers of health services and has identified a number of key issues. These include: (1) Definitions, roles, and settings (2) Stakeholder identification and selection (3) Levels of engagement, (4) Evaluation of engagement, (5) Documentation and transparency, and (6) Conflict of interest management. In this paper, we discuss these issues and our plan to develop guidance to facilitate stakeholder engagement in all stages of the development of health and healthcare guideline development.

'They don't really know why they're here' mental health professionals' perspectives of consumer representatives

There are several barriers to meaningful, non-tokenistic consumer representation in mental health, including stigma and negative attitudes towards consumers. The aim of this study was to examine mental health professionals' perspectives about collaborating with consumer representatives. Semi-structured interviews were conducted with 11 mental health professionals across Australia. Informed by the social identity framework, the findings are discussed in relation to the themes of (1) the need for greater clarity about the roles of consumer representatives, (2) perceptions about whether consumer representatives are held to equal professional standards, (3) understandings of consumers' place in organizational hierarchies, (4) facilitating more meaningful collaboration between consumer representatives and non-consumer health professionals and (5) the blurring of these identities when mental health professionals have lived experience. Findings suggest that the social identities of mental health consumer representatives (along with their organizational roles) are often unclear and need development within healthcare organizations. Leaders can provide guidance on group boundaries to enable effective collaboration. The implications for healthcare organizations and policy include the provision of clear frameworks for collaborative mental healthcare and clear roles, terminology and responsibilities for mental health consumer representatives.

Pharmaceutical industry relationships with oncologists in sub-Saharan Africa

Health-care systems in sub-Saharan Africa are considered to be new markets for pharmaceutical companies. This perception is particularly relevant within oncology, as the pharmaceutical industry has changed strategic priorities in the past 10 years to focus on cancer. Since the 1930s, pharmaceutical companies have used advertisements, sample drugs, gifts, paid speaking engagements, advisory boards, and trips to conferences to influence clinical practice and policy. A large amount of literature describes the commonness of these practices and their effects on the behaviour of doctors. However, these data come almost exclusively from high-income countries. Industry-doctor relationships are increasingly common in sub-Saharan Africa and other low-income and middle-income countries. Although there are undoubtedly risks of industry engagement in low-income and middle-income countries, many programmes with educational, research, and clinical value would not occur in these countries without industry support. Thus, what is known about these relationships in high-income countries will not necessarily apply in low-income and middle-income countries. There is a need for widespread discussion about industry-oncologist interactions across the African continent and context-specific data to understand the potential risks and benefits of these relationships.

Donations Made and Received: A Study of Disclosure Practices of Pharmaceutical Companies and Patient Groups in Canada

Given the increasing role of patient groups in pharmaceutical policy-making in Canada, this observational study was undertaken to determine whether companies that are members of Innovative Medicines Canada (IMC) list, on their publicly available websites, the names of patient groups that they make donations to and reciprocally, whether patient groups publicly list the names of the companies that they receive donations from. Websites of IMC members were searched for the names of the patient groups receiving donations, value of the donations and year the donations were made. The website of each patient group that was listed as receiving a donation was then searched for information about the name of companies making donations along with the value of the donations, year the donations were made and percent of the patient groups' income represented by the donation. For donations over $50 000, an attempt was made to match donations that companies made to donations that patient groups received. Eleven of 44 IMC members reported making 165 donations to 114 different patient groups. Seventy-nine of these 114 groups reported receiving 373 donations from IMC members. Information about the value of donations, the year that they were given and received and the percent of patient groups' income that they represented was limited. Donations made and received could not be matched because of the absence of information about the donations. Reporting on websites about donations by both companies and patient groups in Canada is haphazard, inconsistent and incomplete. Reforms are need to both the way that companies and patient groups report donations.

PROTOCOL: Conflict of interest issues when engaging stakeholders in health and healthcare guideline development: a systematic review

This is the protocol for a Campbell systematic review. The overall objective of this study is to gather and summarize the existing literature on conflict of interest issues when engaging stakeholders in guideline development.

National patient groups in Canada and their disclosure of relationships with pharmaceutical companies: a cross-sectional study

OBJECTIVES

This study investigates the information and policies that Canadian patient groups post on their publicly available websites about their relationships with pharmaceutical companies.

DESIGN

Cross-sectional study.

SETTING

Canadian national patient groups.

PARTICIPANTS

Ninety-seven patient groups with publicly available websites.

INTERVENTIONS

Each patient group was contacted by email. Information from patient groups' websites was collected about: total annual revenue for the latest fiscal year, year revenue was reported, revenue from pharmaceutical company donors, purpose of the donation, presence of donors' logos on the website and hyperlinks to donors' websites, previous and current employment information about board members and staff, external audits about the group's finances and whether the group endorses products made by donors. Analysis of publicly available policies looking at: board and/or advisory board, acceptance of donations and revenue generation, independence of decision-making, endorsements, assistance to and/or interactions between patient members from a donor or another company/person acting on behalf of a donor and audits/monitoring/compliance.

PRIMARY AND SECONDARY OUTCOME MEASURES

Number of patient groups posting information on their websites about their relationships with pharmaceutical companies; the presence and contents of patient group policies covering different topics about relationships with pharmaceutical companies.

RESULTS

Fifty-three (54.6%) of 97 groups reported donations from pharmaceutical companies. Forty-one (42.3%) groups showed the logos of pharmaceutical companies on their websites and 22 (53.7%) had hyperlinks to pharmaceutical company websites. Twenty-five (25.8%) of these groups endorsed pharmaceutical products produced by brand-name companies that had donated to the groups. Twenty-six (26.8%) groups had policies that dealt with relationships with pharmaceutical companies.

CONCLUSIONS

Pharmaceutical industry funding of the included patient groups was common. Despite this, relatively little information was provided on patient group websites about their relationships with pharmaceutical companies. Only 26 out of 97 groups had publicly available policies that directly dealt with their relationships with pharmaceutical companies.

Reforming the MRI system: the Israeli National Program to shorten waiting times and increase efficiency

Background

Long waiting times (WT) for Magnetic Resonance Imaging (MRI) are a challenge in many countries and demand is forecast to increase with ageing populations. Since MRI is essential for diagnosis in numerous medical conditions, timely performance is of the utmost importance.

Objective

To describe the multi-faceted program developed by the Israel Ministry of Health (MoH) to shorten WT for MRI and increase efficiency, and to examine lessons that can be learned for other health systems.

Data sources

Data were obtained from the Israel MoH from 2015–2019.

Methods

The plan used multiple strategies and comprised the following elements: providing additional scanners, dedicating additional personnel to MRI units, maximizing efficiency, establishing a training program for radiographers and a fellowship program for radiologists, introducing financial incentives to health maintenance organizations and implementing a computerized monitoring system.

Results

A substantial reduction in mean WT was demonstrated, from 52 days in 2015, to 24 days in 2016 and 2017. This was followed by a slight increase to 26 and 32 days in 2018 and 2019, respectively. The relative decline in WT from 2015 to 2019 was 38.5%. The number of scanners doubled during this period while the number of radiographers and radiologists with formal MRI training increased.

Conclusions

The broad scope of this comprehensive reform was successful in addressing long WT and improving care provision from a wide perspective: economic, workforce and infrastructure. Bottlenecks in the MRI system cannot be addressed from a single angle, rather requiring a whole system approach.

Financial relationships between patient and consumer representatives and the health industry: A systematic review

Background

Patients and consumers are increasingly engaged in health policymaking, research and drug regulation. Having financial relationships with the health industry creates situations of conflicts of interest (COI) and might compromise their meaningful and unbiased participation.

Objective

To synthesize available evidence on the financial relationships between the health industry and patient and consumer representatives and their organizations.

Methods

We systematically searched MEDLINE and EMBASE. We selected studies and abstracted data in duplicate and independently. We reported on outcomes related to financial relationships of individuals with, and/or funding of organizations by the health industry.

Results

We identified a total of 14 510 unique citations, of which 24 reports of 23 studies were eligible. Three studies (13%) addressed the financial relationship of patient and consumer representatives with the health industry. Of these, two examined the proportion of public speakers in drug regulatory processes who have financial relationships; the proportions in the two studies were 25% and 19% respectively. Twenty studies (87%) addressed funding of patient and consumer organizations. The median proportion of organizations that reported funding from the health industry was 62% (IQR: 34%‐69%) in questionnaire surveys, and 75% (IQR: 58%‐85%) in surveys of their websites. Among organizations for which there was evidence of industry funding, a median proportion of 29% (IQR: 27%‐44%) acknowledged on their websites receiving that funding.

Conclusion

Financial relationships between the health industry and patient and consumer representatives and their organizations are common and may not be disclosed. Stricter regulation on disclosure and management is needed.