Financial conflict-of-interest policies in clinical research: issues for clinical investigators

Suppressing Scientific Discourse on Vaccines? Self-perceptions of researchers and practitioners

The controversy over vaccines has recently intensified in the wake of the global COVID-19 pandemic, with calls from politicians, health professionals, journalists, and citizens to take harsh measures against so-called "anti-vaxxers," while accusing them of spreading "fake news" and as such, of endangering public health. However, the issue of suppression of vaccine dissenters has rarely been studied from the point of view of those who raise concerns about vaccine safety. The purpose of the present study was to examine the subjective perceptions of professionals (physicians, nurses, researchers) involved with vaccines through practice and/or research and who take a critical view on vaccines, about what they perceive as the suppression of dissent in the field of vaccines, their response to it, and its potential implications on science and medicine. Respondents reported being subjected to a variety of censorship and suppression tactics, including the retraction of papers pointing to vaccine safety problems, negative publicity, difficulty in obtaining research funding, calls for dismissal, summonses to official hearings, suspension of medical licenses, and self-censorship. Respondents also reported on what has been termed a "backfire effect" - a counter-reaction that draws more attention to the opponents' position. Suppression of dissent impairs scientific discourse and research practice while creating the false impression of scientific consensus.

A Ray of Sunshine: Transparency in Physician-Industry Relationships Is Not Enough

Gifts from pharmaceutical and medical device companies to physicians in the United States have been reported since 2014, through the Physician Payments Sunshine Act. Although researchers have utilized these data to publish many studies on conflicts of interest (COIs) and prescribing behavior, there is no evidence that physician behavior regarding COI has changed, or that employers, meeting organizers, or medical journals are excluding physicians based on conflicts of interest. Disclosure is necessary but not sufficient to address the damage that industry relationships causes to medical knowledge and public health.

Influence and management of conflicts of interest in randomised clinical trials: qualitative interview study

OBJECTIVE

To characterise and analyse the experiences of trial researchers of if and how conflicts of interest had unduly influenced clinical trials they had worked on, what management strategies they had used to minimise any potential influence, and their experiences and views on conflicts of interest more generally.

DESIGN

Qualitative interview study.

PARTICIPANTS

Trial researchers who had participated in at least 10 clinical trials with methodological or statistical expertise. Researchers differed by geographical location, educational background, and experience with different types of funders. Interviewees were identified by searches on Web of Science and snowball sampling. 52 trial researchers were approached by email; 20 agreed to be interviewed.

SETTING

Interviews conducted by telephone, recorded, transcribed verbatim, imported to NVivo 12, and analysed by systematic text condensation. Semistructured interviews focused on financial and non-financial conflicts of interest.

RESULTS

The interviewees had participated in a median of 37.5 trials and were mainly male physicians who had experience with commercial and non-commercial trial funders. Two predefined themes (influence of conflicts of interest and management strategies) and two additional themes (definition and reporting of conflicts of interest) emerged. Examples of perceived influence of conflicts of interest were: choice of inferior comparator, manipulation of the randomisation process, prematurely stopping the trials, fabrication of data, blocking access to data, and spin (eg, overly favourable interpretation of the results). Examples of strategies to manage conflicts of interest were: disclosure procedures, exclusion of the funder from design and analysis, independent committees, contracts ensuring complete access to the data, and no restriction by the funder on analysis and reporting. Interviewees used different definitions or thresholds for what they considered to be conflicts of interest, and they described different criteria for when to report them. Some interviewees considered non-commercial financial conflicts of interest (eg, funding of trials by governmental health agencies with a political agenda) to be equally or more important than commercial financial conflicts of interest (eg, funding by drug and device companies), but more challenging to report and manage.

CONCLUSION

This study described how trial researchers perceive conflicts of interest unduly influencing clinical trials they had worked on, and the management strategies they used to prevent these influences. The results indicated considerable variability in researchers' understanding of what conflicts of interest are and when they should be reported.

How Single Institutional Review Boards Manage Their Own Conflicts of Interest: Findings From a National Interview Study

PURPOSE

Conflicts of interest (COIs) are important ethical concerns because they may affect scientific decision making, research integrity, and the safety and fairness of studies. No research to date has examined COIs of single institutional review boards (sIRBs), which are now mandated by the National Institutes of Health, and will be by the revised Common Rule in 2020, for all multisite research. This study investigated how different types of sIRBs manage their own COIs by documenting existing processes for and comparing commercial, government, and academic sIRBs.

METHOD

One hundred three personnel from 20 commercial, government, or academic sIRBs participated in semistructured interviews about their processes for and experiences with managing COIs when conducting multisite research review.

RESULTS

Variability in COI management policies exist across types of sIRBs. Commercial sIRBs were aware of their own COIs given their for-profit model, and managed them by using firewalls, relying on external reviewers, and turning down potential clients. Government sIRBs described unique COIs stemming from the same agency funding the sIRB and the research being reviewed. They addressed these by discussing concerns about COIs, using firewalls, relying on nonaffiliated reviewers, and having broad COI policies. In contrast to commercial and government sIRBs, academic sIRBs did not report any specific policies to manage their COIs, which are similar to those of local IRBs.

CONCLUSIONS

As sIRBs become increasingly common, researchers will need to weigh the different COIs inherent to each type of sIRB. Additionally, academic sIRBs may consider implementing specific policies for managing their COIs.

Of Straws, Camels, Research Regulation, and IRBs

Institutional review boards (IRBs) have become beleaguered by a growth in responsibilities related to research oversight in the past several decades. A number of regulatory bodies have appeared in response to these novel and complex responsibilities, seeking to respond to among other issues, conflicts of interest, new technologies, and the potential misuse of research findings. Here, we examine several examples of these novel regulatory bodies as well as a number of concerns related to them that have been largely unacknowledged. Evidence suggests that there can be disharmony and conflicts between these regulatory bodies and IRBs, a lack of clarity with regard to their roles and responsibilities, as well as shortcomings within these entities that, at times, look a lot like the worries that have long been raised in relation to IRBs. We offer a brief discussion of how some of these concerns might be ameliorated, either through a significant restructuring of the system of research oversight, or perhaps through smaller changes to these regulatory bodies.

The institutional workers of biomedical science: Legitimizing academic entrepreneurship and obscuring conflicts of interest

Given growing initiatives incentivizing academic researchers to engage in 'entrepreneurial' activities, this article examines how these academic entrepreneurs claim value in their entrepreneurial engagements, and navigate concerns related to conflicts of interest. Using data from qualitative interviews with twenty-four academic entrepreneurs in Canada, we show how these scientists value entrepreneurial activities for providing financial and intellectual resources to academic science, as well as for their potential to create impact through translation. Simultaneously, these scientists claimed to maintain academic norms of disinterested science and avoid conflicts of interest. Using theories of institutional work, we demonstrate how entrepreneurial scientists engage in processes of institutional change-through-maintenance, drawing on the maintenance of academic norms as institutional resources to legitimize entrepreneurial activities. As entrepreneurial scientists work to legitimize new zones of academic scientific practice, there is a need to carefully regulate and scrutinize these activities so that their potential harms do not become obscured.

A Systematic Review and Appraisal of Clinical Practice Guidelines for Musculoskeletal Soft Tissue Injuries and Conditions

BACKGROUND

Clinical practice guidelines (CPGs) are published by several sports medicine institutions. A systematic evaluation can help identify the highest quality CPGs for clinical use and identify any deficiencies that remain.

PURPOSE

To identify and appraise CPGs relevant to clinical sports medicine professionals.

STUDY DESIGN

Systematic review.

METHODS

Predetermined selection criteria were utilized by 2 reviewers who independently identified published CPGs before January 1, 2014. CPGs were excluded if they focused on injured workers, radiological criteria, medical pathology, or the axial skeleton (back/neck). The remaining guidelines were scored by 6 reviewers with different clinical backgrounds using the Appraisal of Guidelines for Research and Evaluation II (AGREE II). Scores lower than 50% indicated deficiency. Scores were also stratified by the publishing institution and anatomic location and compared using Kruskal-Wallis tests. The Spearman correlation coefficient was used to assess the range of interobserver agreement between the evaluators.

RESULTS

Seventeen CPGs met the inclusion criteria. The majority of guidelines pertained to the knee, ankle, or shoulder. Interobserver agreement was strong ( r = 0.548-0.740), and mean total scores between nonsurgical (107.8) and surgical evaluators (109.3) were not statistically different. Overall guideline quality was variable but not deficient for 16 of 17 guidelines (>50%), except regarding clinical "applicability" and "editorial independence." No difference was found between CPGs of the knee, shoulder, foot/ankle, or chronic conditions. However, CPG publishing institutions had significantly different scores; the American Academy of Orthopaedic Surgeons (AAOS) guidelines scored significantly higher (141.4) than the total mean score (108.0).

CONCLUSION

The overall quality of sports medicine CPGs was variable but generally not deficient, except regarding applicability and editorial independence. Bias through poor editorial independence is a concern. To improve future guideline quality, authors should pay particular attention to these areas and use existing highest quality guidelines, or the AGREE II instrument, as templates. CPGs dedicated to anatomic areas other than the knee, ankle, and shoulder are needed.

A Radiologist's Guide to the Industry: A Methodical Approach to Physician-Industry Relationships in Radiology

In the last century, rapidly advancing technological innovations have become essential components of modern healthcare, increasing the frequency and necessity of interactions between physicians and industry. These interactions have the potential to bias objectivity and should be approached carefully. A recent JACR article by Harvey et al, highlighted 2014 CMS data, which reported that only 4% of radiologists had interactions with industry, coming in second lowest amongst all 19 reported specialties. However, when managed appropriately, physician-industry relationships can mutually benefit patients, research, payers, providers, hospitals and the medical industry. In order to maintain relevance in the evolving healthcare landscape, it is imperative that radiologists establish, maintain, and expand relationships with industry. To help providers work within the ethical safety of institutional guidelines, while still promoting innovation, we propose a methodical approach with 7 key components to consider when developing appropriate physician-industry relationships or evaluating new products.

Food for thought? Potential conflicts of interest in academic experts advising government and charities on dietary policies

BACKGROUND

A conflict of interest (CoI) can occur between public duty and private interest, in which a public official's private-capacity interest could improperly influence the performance of their official duties and responsibilities. The most tangible and commonly considered CoI are financial. However, CoI can also arise due to other types of influence including interpersonal relationships, career progression, or ideology. CoI thus exist in academia, business, government and non-governmental organisations. However, public knowledge of CoI is currently limited due to a lack of information. The mechanisms of managing potential conflicts of interest also remain unclear due to a lack of guidelines. We therefore examined the independence of academic experts and how well potential CoI are identified and addressed in four government and non-governmental organisations in the UK responsible for the development of food policy.

METHODS

Policy analysis. We developed an analytical framework to explore CoI in high-level UK food policy advice, using four case studies. Two government policy-making bodies: Department of Health 'Obesity Review Group' (ORG), 'Scientific Advisory Committee on Nutrition' (SACN) and two charities: 'Action on Sugar' (AoS), & 'Heart of Mersey' (HoM). Information was obtained from publicly available sources and declarations. We developed a five point ordinal scale based upon the ideology of the Nolan Principles of Public Life. Group members were individually categorised on the ordinal ConScale from "0", (complete independence from the food and drink industry) to "4", (employed by the food and drink industry or a representative organisation).

RESULTS

CoI involving various industries have long been evident in policy making, academia and clinical practice. Suggested approaches for managing CoI could be categorised as "deny", "describe", or "diminish". Declared CoI were common in the ORG and SACN. 4 out of 28 ORG members were direct industry employees. In SACN 11 out of 17 members declared industry advisory roles or industry research funding. The two charities appeared to have equally strong academic expertise but fewer conflicts. No HoM members declared CoI. 5 out of 21 AoS members declared links with industry, mainly pharmaceutical companies. We were unable to obtain information on conflicts for some individuals.

CONCLUSIONS

Conflicts of interest are unavoidable but potentially manageable. Government organisations responsible for policy development and implementation must institutionalize an approach to identify (disclose) and manage (mitigate or eliminate) perceived and actual CoI to improve public confidence in government decision-making relevant to food policy.

The impact of industry on oncology research and practice

Public scrutiny has increased over potential conflicts of interest among oncology researchers and providers. Given the increased prevalence and complexity of industry relationships, oncologists are increasingly faced with ethical challenges when navigating their financial relationships with industry. Oncologists are continually dealing with changing conflict of interest policies within academic centers and professional societies. With the recent passage of The Sunshine Act, oncologists are beginning to understand the repercussions of this new law. The consequences of the increasing use of direct-to-consumer advertising on patients with cancer are also unclear. Finally, industry's perspective on the evolution of these relationships is not clearly understood. This manuscript discusses issues related to industry's influence on oncology practice and research.

Conflict of Interest in Research—The Clinician Scientist’s Perspective

Conflict of interest (COI) in research represents situations that pose risks of undue influence on scientific objectivity and judgment because of secondary interests. This is complex but is inherent to biomedical research. The role of a clinician scientist can be conflicted when scientific objectivity is perceived to compete with scientific success (publications, grants), partiality to patients (clinical trials), obligations to colleagues (allowing poor scholarship to pass), research sponsors (industry), and financial gains (patents, royalties). While there are many ways which COIs can occur in research, COI mitigations remain reliable. Collaborations between investigators and industry are valuable to the development of novel therapies and undue discouragement of these relationships may inadvertently harm the advancement of healthcare. As a result, proper management of COI is fundamental and crucial to the maintenance of long-term, mutually beneficial relationships between industry and academia. The nature of COI in research and methods of mitigation are discussed from the perspective of a clinician scientist. Key words: Academia, Disclosure, Industry

Guideline funding and conflicts of interest: article 4 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report

INTRODUCTION

Professional societies, like many other organizations around the world, have recognized the need to use more rigorous processes to ensure that healthcare recommendations are informed by the best available research evidence. This is the fourth of a series of 14 articles prepared to advise guideline developers in respiratory and other disease. It focuses on commercial funding of guidelines and managing conflict of interest effectively in the context of guidelines.

METHODS

In this review, we addressed the following topics and questions. (1) How are clinical practice guidelines funded? (2) What are the risks associated with commercial sponsorship of guidelines? (3) What relationships should guideline committee members be required to disclose? (4) What is the most efficient way to obtain complete and accurate disclosures? (5) How should disclosures be publicly shared? (6) When do relationships require management? (7) How should individual conflicts of interest be managed? (8) How could conflict of interest policies be enforced? The literature review included a search of PubMed and other databases for existing systematic reviews and relevant methodological research. Our conclusions are based on available evidence, consideration of what guideline developers are doing, and workshop discussions.

RESULTS AND DISCUSSION

Professional societies often depend on industry funding to support clinical practice guideline development. In addition, members of guideline committees frequently have financial relationships with commercial entities, are invested in their intellectual work, or have conflicts related to clinical revenue streams. No systematic reviews or other rigorous evidence regarding best practices for funding models, disclosure mechanisms, management strategies, or enforcement presently exist, but the panel drew several conclusions that could improve transparency and process.

Correlation between financial relationships with commercial interests and research prominence at an oncology meeting

PURPOSE

Little is known about the effects of financial relationships between biomedical researchers and industry (financial conflicts of interest [FCOIs]) on research prominence. We examined the prevalence of FCOIs in oncology and associations between FCOIs and research prominence among abstracts presented at American Society of Clinical Oncology (ASCO) annual meetings.

METHODS

We analyzed 20,718 abstracts presented at ASCO meetings in 2006 and 2008 to 2011. Measures included the following: financial relationships, peer review score (PRS), and meeting placement prominence (descending order of prominence: plenary session, clinical science symposium, oral presentation, poster discussion, general posters, and publish only).

RESULTS

Of 20,718 abstracts, 36% reported at least one author with an FCOI. The proportion of abstracts with any FCOI increased from 33% in 2006 to 38% in 2011 (P < .001). Abstracts with FCOIs had significantly higher meeting prominence compared with publish only and general poster abstracts. The odds ratios compared with general posters were 7.3 for plenary session, 2.2 for clinical science symposium, 1.9 for oral presentation, and 1.7 for poster discussion (P < .001). Abstracts with FCOIs had significantly better PRSs compared with those without FCOIs. For all abstracts, PRS was 2.76 (95% CI, 2.75 to 2.77) with FCOIs compared with 3.01 (95% CI, 3.001 to 3.02) without FCOIs (P < .001). Omitting publish-only abstracts, PRS was 2.62 (95% CI, 2.61 to 2.63) with FCOIs compared with 2.73 without FCOIs (95% CI, 2.71 to 2.73).

CONCLUSION

Abstracts with FCOIs had more prominent meeting placement and better PRSs. FCOIs were reported more frequently by year, suggesting an increasing influence of industry on cancer research, greater disclosure, or both.

Quality of reporting and evidence in American Academy of Pediatrics guidelines

OBJECTIVES

The primary objectives were to evaluate the quality of development and reporting of American Academy of Pediatrics (AAP) guidelines and to determine the level of evidence underlying the recommendations.

METHODS

Two reviewers scored each guideline by using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument and determined the level of evidence for each recommendation in each guideline. Subgroup analyses compared AAP guidelines published before and after key changes in AAP guideline development policy and compared internal with endorsed guidelines.

RESULTS

For the 28 current guidelines, the highest average scores on AGREE-II were in scope and purpose (75%) and clarity of presentation (73%). The lowest average scores were in editorial independence (17%) and applicability (30%). The only domain that improved after AAP policy updates was editorial independence (P = .01). Of the 190 treatment recommendations, 43% were based on experimental studies, 30% on observational studies, and 27% on expert opinion or no reference. Compared with early guidelines, late guidelines included a higher proportion of treatment recommendations based on experimental studies (P = .05).

CONCLUSIONS

There was no clear improvement in the quality of development and reporting of AAP clinical practice guidelines over time. Routine application of AGREE-II to guideline development could enhance guideline quality. The proportion of guideline recommendations based on experimental evidence has increased slightly over time. Pediatric research agendas should be matched to vital gaps in the evidence underlying pediatric guidelines.

Determinants and associated factors influencing medication adherence and persistence to oral anticancer drugs: a systematic review

BACKGROUND AND AIMS

The use of oral anticancer drugs has increased in modern oncology treatment. The move from intravenous treatments towards oral anticancer drugs has increased the patients' own responsibility to take oral anticancer drugs as being prescribed. High rates of non-adherence to oral anticancer drugs have been reported. A systematic literature review was conducted to gain insight into determinants and associated factors of non-adherence and non-persistence in patients taking oral anticancer therapy.

REVIEW METHODS

PubMed, Cochrane, Web of Science and Cinahl were systematically searched for studies focusing on determinants and associated factors of medication non-adherence and non-persistence to oral anticancer drugs. The methodological quality of the included studies was assessed by two independent reviewers. No studies were excluded based on the quality assessment.

RESULTS

Twenty-five studies were included and systematically reviewed. The quality of the studies was moderate. Associated factors influencing medication non-adherence and non-persistence to oral anticancer drugs are multifactorial and interrelated. Older and younger age, and the influence of therapy related side effects were found to be predominant factors.

CONCLUSION

Non-adherence and non-persistence to oral anticancer drug therapy are complex phenomena. More qualitative research is needed to facilitate the development of patient tailored complex interventions by exploring patients' needs and underlying processes influencing medication non-adherence and non-persistence to oral anticancer drugs.

Transparency in research and its effect on the perception of research integrity

Pharmaceutical companies routinely engage faculty from academic medical centers to participate in biomedical research. Faculty contribute expertise and research subjects and often receive considerable compensation for their efforts. Because the role of the researcher can be compromised by financial conflicts of interest, disclosure of such relationships is routinely required. The effect of such disclosure is not entirely clear, however, and studies have yielded inconsistent results on how those receiving financial disclosures perceive the integrity of the research. Reviewing the literature, we conclude there is little consensus on how the disclosure of a financial relationship with an industry sponsor affects confidence in the research. We also conclude that is it unclear whether the new Patient Protection and Affordable Care Act will substantially alter the landscape.

A common standard for conflict of interest disclosure in addiction journals

This paper presents a common standard for conflict of interest disclosure. The common standard was drafted by the authors, following consultation with a multi-disciplinary group of journal editors, publishers, bioethicists and other academics. It is presented here for the benefit of authors, editorial managers, journal editors and peer reviewers to stimulate discussion and to provide guidance to authors in reporting real, apparent and potential conflicts of interest. It is particularly relevant to addiction specialty journals because of the potential conflicts of interest associated with funding from the alcohol, tobacco, pharmaceutical and gambling industries. Following an appropriate period of vetting the common standard within the scientific community, it is recommended that journal editors adopt journal policies and reporting procedures that are consistent across journals.

National evaluation of policies on individual financial conflicts of interest in Canadian academic health science centers

BACKGROUND

Conflicts of interest (COI) in research are an important emerging topic of investigation and are frequently cited as a serious threat to the integrity of human participant research.

OBJECTIVE

To study financial conflicts of interest (FCOI) policies for individual investigators working in Canadian academic health centers.

DESIGN

Survey instrument containing 61 items related to FCOI.

SETTING

All Canadian academic health science centers (universities with faculties of medicine, faculties of medicine and teaching hospitals) were requested to provide their three primary FCOI policies.

MEASUREMENTS

Number of all centers and teaching hospitals with policies addressing each of the 61 items related to FCOI.

MAIN RESULTS

Only one item was addressed by all 74 centers. Thirteen items were present in fewer than 25% of centers. Fewer than one-quarter of hospitals required researchers to disclose FCOI to research participants. The role of research ethics boards (REBs) in hospitals was marginal.

LIMITATIONS

Asking centers to identify only three policies may not have inclusively identified all FCOI policies in use. Additionally, policies at other levels might apply. For instance, all institutions receiving federal grant money must comply with the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans.

CONCLUSIONS

Canadian centers within the same level (for instance, teaching hospitals) differ significantly in the areas that their policies address and these policies differ widely in their coverage. Presently, no single policy in any Canadian center informs researchers about the broad range of individual FCOI issues. Canadian investigators need to understand the environment surrounding FCOI, be able to access and follow the relevant policies and be confident that they can avoid entering into a FCOI.

Effects of disclosing financial interests on participation in medical research: a randomized vignette trial

BACKGROUND

Little is known about the effects of investigators' financial disclosures on potential research participants.

METHODS

We conducted a vignette trial in which 470 participants in a telephone survey were randomly assigned to receive a simulated informed consent document that contained 1 of 2 financial disclosures (per capita payments to the research institution or equity ownership by the investigator) or no disclosure. The main outcome measures were trust in medical research and willingness to participate in a hypothetical clinical trial.

RESULTS

Participants in the equity group reported less willingness to participate than participants in the per capita payments group (P = .01) and the no disclosure group (P = .03). Trust in the investigator was highest in the per capita payments group and lowest in the equity group (P < .001). Trust among participants who received no disclosure was also greater than trust among participants in the equity group (P = .04) but did not differ significantly from trust among participants in the per capita payments group (P = .15). Participants in the equity group made 3 times as many negative comments as participants in the per capita payments group; and 10 participants in the equity group spontaneously said they would not participate in the hypothetical trial because of the financial interest, compared with only 1 such participant from the other groups.

CONCLUSIONS

Although investigators' financial disclosures in research do not substantially affect willingness to participate, potential research participants are more troubled by equity interests than by per capita payments.

Is research presented at the scoliosis research society annual meeting influenced by industry funding?

STUDY DESIGN

All abstracts submitted to the 2006 SRS annual meeting were reviewed.

OBJECTIVE

To determine the rate of funding in abstracts submitted for presentation at the 2006 Annual Scoliosis Research Society (SRS) meeting and whether funding produced bias toward a positive outcome.

SUMMARY OF BACKGROUND DATA

Financial conflicts of interest have been attributed to bias in research.

METHODS

Three members the SRS Program Committee reviewed 610 abstracts submitted for presentation at the 2006 annual meeting. The committee's average grade was correlated with type of funding (industry, professional society, university); abstract conclusions (favorable, unfavorable, or only descriptive); and subject category [adolescent idiopathic scoliosis (AIS), motion preservation, etc.].

RESULTS

Of the 610 submitted articles, 72% (n = 440) were unfunded. Of the 170 funded articles, 140 were supported by industry, 7 by government agency, 8 by professional societies, 4 by universities, and 11 by private foundations. There was no statistically significant difference between the reviewers' grades of funded versus unfunded articles (P = 0.39). Comparing AIS articles to all the other categories, the number of funded articles were significantly greater only in motion preservation (P < 0.001) and genetics (P = 0.039). When a consultant/employee relationship was present, there was a significant difference in the proportion of funded articles and favorable findings (P = 0.048).

CONCLUSION

The higher percentage of funded articles in motion preservation and genetics compared to AIS articles could reflect a bias in those 2 areas. However, although there were more funded articles in those 2 areas there were not more funded, favorable articles (motion preservation P = 0.059, and genetics P = 0.3). Thus, certain categories attracted more funding than others but there was not a bias toward favorable findings within the funded articles unless the funding was due to a consultant/employee relationship.

Reporting science and conflicts of interest in the lay press

BACKGROUND

Forthright reporting of financial ties and conflicts of interest of researchers is associated with public trust in and esteem for the scientific enterprise.

METHODS/PRINCIPAL FINDINGS

We searched Lexis/Nexis Academic News for the top news stories in science published in 2004 and 2005. We conducted a content analysis of 1152 newspaper stories. Funders of the research were identified in 38% of stories, financial ties of the researchers were reported in 11% of stories, and 5% reported financial ties of sources quoted. Of 73 stories not reporting on financial ties, 27% had financial ties publicly disclosed in scholarly journals.

CONCLUSIONS/SIGNIFICANCE

Because science journalists often did not report conflict of interest information, adherence to gold-standard recommendations for science journalism was low. Journalists work under many different constraints, but nonetheless news reports of scientific research were incomplete, potentially eroding public trust in science.

Defining financial conflicts and managing research relationships: an analysis of university conflict of interest committee decisions

Despite a decade of federal regulation and debate over the appropriateness of financial ties in research and their management, little is known about the actual decision-making processes of university conflict of interest (COI) committees. This paper analyzes in detail the discussions and decisions of three COI committees at three public universities in California. University committee members struggle to understand complex financial relationships and reconcile institutional, state, and federal policies and at the same time work to protect the integrity of the scientific process, the autonomy and intellectual freedom of their faculty colleagues and students, and the financial interests of the university.

Comparison of conflict of interest policies and reported practices in academic medical centers in the United States

The authors reviewed the conflict of interest policies of 9 academic medical centers in the United States and interviewed members of the Institutional Review Boards (IRBs) and Conflict of Interest Committees (COICs) at those institutions. They found that many institutions used processes for reporting and managing conflicts of interest that were more decentralized than the processes described in their policies. Also, most institutions had no clear and comprehensive policy to guide investigators regarding disclosure of conflicts of interest to potential research participants. Considerable differences in understanding of conflict of interest policies were observed between IRB and COIC officials.

Attitudes Toward Research Participation and Investigator Conflicts of Interest Among Advanced Cancer Patients Participating in Early Phase Clinical Trials

Purpose

Although both financial and intrinsic conflicts of interest can exist throughout the drug development process, little is known about how advanced cancer patients enrolled onto early phase clinical trials perceive investigator conflicts of interests.

Patients and Methods

We interviewed 102 advanced cancer patients enrolled onto phase I clinical trials using a standardized survey that addressed multiple issues related to conflicts of interest and research participation.

Results

Fifty-five percent of patients would not be concerned if physicians involved in running a clinical trial had financial conflicts of interest, whereas 65% of patients would be concerned if physicians involved in running a trial had intrinsic conflicts of interest. Most patients reported that potential conflicts of interest should be disclosed to patients on research trials (52% for financial conflicts of interest and 61% for more intrinsic conflicts of interest). Most patients would be willing to participate in trials after learning conflict of interest information (63%). Younger patients expressed more concern regarding financial conflict of interest than older patients (odds ratio, 6.22; 95% CI, 1.41 to 27.24).

Conclusion

Patients with advanced cancer are equally, if not more, concerned about traditional intrinsic conflicts of interest as compared with financial conflicts of interest. Patients generally believed that conflict of interest information should be disclosed to research participants. The fact that younger patients expressed more concern about financial conflicts of interest may have the potential to influence clinical trial participation rates. The actual impact of conflict of interest disclosure to research subjects needs to be evaluated more carefully.

Atypical antipsychotics for the treatment of bipolar disorder: more shadows than lights

Atypical antipsychotics are utilised more frequently for the treatment of bipolar disorder than first-generation antipsychotics because of their improved neurological tolerability. Furthermore, recent studies suggest that psychiatric outcomes are improved in patients treated with atypical agents. The aim of this article is to review the studies evaluating the effectiveness of atypical antipsychotics in treating acute bipolar episodes (bipolar mania, bipolar depression and mixed episodes), as well as those investigating the effectiveness of atypical antipsychotics as maintenance treatment for the disorder. Because of several relevant methodological limitations affecting the vast majority of clinical trials, evidence-based information about the effectiveness of atypical antipsychotics in treating bipolar disorder is somewhat discouraging. Moreover, data indicating effectiveness in managing the acute manic phase and in long-term maintenance treatment are quantitatively robust only for olanzapine. However, olanzapine seems to have no advantages in terms of tolerability and therapy compliance when compared with classical mood stabilisers or first-generation antipsychotics. In addition, only a few studies have investigated the efficacy of atypical antipsychotics for treating bipolar depression. Hence, information regarding the effectiveness of such medications in treating this specific phase of bipolar disorder should be considered as still preliminary. Given this situation, further independent and well-designed studies are urgently needed before definitive conclusions on the effectiveness of most atypical antipsychotics in the different clinical situations characterising the natural course of bipolar disorder can be drawn.

The tobacco industry's role in the 16 Cities Study of secondhand tobacco smoke: do the data support the stated conclusions?

BACKGROUND

Since 1996, the tobacco industry has used the 16 Cities Study conclusions that workplace secondhand tobacco smoke (SHS) exposures are lower than home exposures to argue that workplace and other smoking restrictions are unnecessary.

OBJECTIVES

Our goal was to determine the origins and objectives of the 16 Cities Study through analysis of internal tobacco industry documents and regulatory agency and court records, and to evaluate the validity of the study's conclusions.

RESULTS

The tobacco industry's purpose in conducting the 16 Cities Study was to develop data showing that workplace SHS exposures were negligible, using these data to stop smoking restrictions by the U.S. Occupational Safety and Health Administration. The extensive involvement of R.J. Reynolds Tobacco Company and the tobacco industry's Center for Indoor Air Research in controlling the study was not fully disclosed. The study's definition of "smoking workplace" included workplaces where smoking was restricted to designated areas or where no smoking was observed. This definition substantially reduced the study's reported average SHS concentrations in "smoking workplaces" because SHS levels in unrestricted smoking workplaces are much greater than in workplaces with designated smoking areas or where no smoking occurred. Stratifying the data by home smoking status and comparing exposures by workplace smoking status, however, indicates that smoke-free workplaces would halve the total SHS exposure of those living with smokers and virtually eliminate SHS exposure for most others.

CONCLUSIONS

Data in the 16 Cities Study reveal that smoke-free workplaces would dramatically reduce total SHS exposure, providing significant worker and public health benefits.

Improving the use of research evidence in guideline development: 4. Managing conflicts of interests

BACKGROUND

The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the fourth of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this.

OBJECTIVES

We reviewed the literature on conflicts of interest to answer the following questions: 1. What is the best way to obtain complete and accurate disclosures on financial ties and other competing interests? 2. How to determine when a disclosed financial tie or other competing interest constitutes a conflict of interest? 3. When a conflict of interest is identified, how should the conflict be managed? 4. How could conflict of interest policies be enforced?

METHODS

We searched PubMed, the Cochrane Methodology Register and selectively searched for the published policies of several organizations, We did not conduct systematic reviews ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments.

KEY QUESTIONS AND ANSWERS

What is the best way to obtain complete and accurate disclosures on financial ties and other competing interests? Although there is little empirical evidence to guide the development of disclosure forms, minimal or open-ended formats are likely to be uninformative. We recommend the development of specific, detailed, structured forms that solicit as much information as possible about the nature and extent of the competing interests. How to determine when a disclosed financial tie or other competing interest constitutes a conflict of interest?* There is no empirical evidence to suggest that explicit criteria are preferable to ad hoc committee decisions when deciding if a disclosed financial tie is a conflict of interest. However, explicit criteria may make decision-making easier. When a conflict of interest is identified, how should the conflict be managed? Descriptive studies suggest that appropriate management strategies are best determined on a case-by-case basis. Thus, WHO should use a wide range of management strategies to address disclosed conflicts of interest, with public disclosure of conflicts associated with each meeting as a minimum and recusal of conflicted individuals as the other extreme. How could conflict of interest policies be enforced? Although there are no empirical studies of the enforcement of conflict if interest policies, descriptive studies of other organizations and institutions suggest that WHO convene a standing committee to review all financial disclosure statements prior to the commencement of committee meetings/hearings and to make management recommendations when necessary. A standard policy requiring all financial ties to be made public (i.e., recorded into the meeting minutes) should reduce the number of problematic cases. In instances where the conflicts seem intractable, a recommendation of recusal may be necessary to protect the greater interests of WHO and its constituents.

Researchers’ Views of the Acceptability of Restrictive Provisions in Clinical Trial Agreements with Industry Sponsors

We conducted a mail survey of 884 U.S. medical school faculty active in clinical research to elicit their views about the acceptability of provisions in contracts for industry-sponsored clinical trials that would restrict investigators' academic freedom and control over trials. We compared their responses to results from a similar survey of research administrators at 107 medical schools. There was substantial variation among clinical researchers in their acceptability judgments, with a relatively large proportion of clinical trial investigators willing to accept provisions that give industry sponsors considerable control over the dissemination of research results. There were significant differences in the perceptions of clinical trial investigators versus other recently published clinical researchers; investigators with a high versus low percentage of research support from industry; junior versus senior faculty; and investigators at institutions with high versus low National Institute of Health (NIH) funding ranks. There was also a significant divergence of views in a number of areas between clinical trialists and research administrators who negotiate clinical trial contracts on their behalf. Medical school faculty could benefit from additional guidance about what their institution views as acceptable parameters for industry-sponsored clinical trial agreements.

Should society allow research ethics boards to be run as for-profit enterprises?

An important mechanism for protecting human research participants is the prior approval of a clinical study by a research ethics board, known in the United States as an institutional review board (IRB). Traditionally, IRBs have been run by volunteer committees of scientists and clinicians working in the academic medical centers where the studies they review are being carried out. However, for-profit organizations are increasingly being hired to conduct ethics reviews. Proponents of for-profit IRBs argue that these IRBs are just as capable as academic IRBs at providing high-quality ethics reviews. Critics argue that for-profit IRBs have a conflict of interest because they generate their income from clients who have a direct financial interest in obtaining approval.

Bias from industry trial funding? A framework, a suggested approach, and a negative result

Bias from funding sources of trials would threaten their validity. Meta-analyses of high quality acute pain and migraine trials were used to explore the hypothesis that industry funding of clinical trials produced more favourable results than non-profit sponsorship. Analyses were planned to evaluate whether industry-sponsored trials had different results from trials funded by academic or other non-profit sources, but of 176 trials, only two were supported by non-profit sources, while 31 provided no statement of support. An alternative method is proposed within industry-sponsored trials, looking at conflicting industry interests for the same drug, used either as test or comparator treatment. Fifty-three trials used an analgesic as test and 90 as comparator, allowing comparisons to be made for aspirin 600/650 mg, ibuprofen 400 mg, paracetamol (acetaminophen) 1000 mg, rofecoxib 50 mg and sumatriptan 50 and 100 mg. Only for sumatriptan 50 and 100 mg, with the outcome of headache response at 2 h, was there any significant difference between the drug used as a test or as a comparator. The direction was for higher (worse) NNTs with sumatriptan as comparator. Investigating potential industry bias through the funding source of trials is unlikely to be adequate because of a dearth of trials funded by non-profit organisations. We propose a method based on potential conflict of interest within industry-sponsored trials. Using this method, established clinical trial results in acute pain and migraine appear to be unbiased.

ELSI priorities for brain imaging

As one of the most compelling technologies for imaging the brain, functional MRI (fMRI) produces measurements and persuasive pictures of research subjects making cognitive judgments and even reasoning through difficult moral decisions. Even after centuries of studying the link between brain and behavior, this capability presents a number of novel significant questions. For example, what are the implications of biologizing human experience? How might neuroimaging disrupt the mysteries of human nature, spirituality, and personal identity? Rather than waiting for an ethical agenda to emerge from some unpredictable combination of the concerns of ethicists and researchers, the attention of journalists, or after controversy is sparked by research that cannot be retracted, we queried key figures in bioethics and the humanities, neuroscience, media, industry, and patient advocacy in focus groups and interviews. We identified specific ethical, legal and social issues (ELSI) that highlight researcher obligations and the nonclinical impact of the technology at this new frontier.

Policies of academic medical centers for disclosing financial conflicts of interest to potential research participants

PURPOSE

To document the current state of institutional review board (IRB) and conflict of interest committee policies regarding disclosures of financial conflicts of interest to potential research participants, and to use this information to identify and share models for effectively achieving disclosure.

METHOD

The authors identified the 123 U.S. academic medical centers that have IRBs and sought their IRB and institutional policies regarding financial conflicts of interest. In February and March 2004, using manual and key word searches, each institution's Web site was searched to identify documents containing information regarding the disclosure of financial conflicts of interest. Letters were sent to 24 institutions that had either no information or incomplete information posted on their Web sites. To assess institutions' guidelines for disclosure, the authors extracted and content coded each institution's information on disclosure.

RESULTS

Relevant information was obtained from 120 (98%) academic medical centers (AMCs), of which 57 (48%) mentioned disclosing financial conflicts to potential research participants. Of these 57, 33 (58%) included verbatim language that could be used in informed consent documents. AMCs' recommendations and requirements for disclosure included details of the financial arrangement, administrative management of conflicts of interest, and encouragement of dialogue between the investigator and the potential research participant.

CONCLUSIONS

Considerable variability exists concerning the specific information that should be disclosed. Most of the AMCs' policies were consistent with the goal of protection from legal liability. Significant questions remain, however, concerning the goals of disclosure and the most effective methods for achieving those goals.

Disclosing conflicts of interest in clinical research: views of institutional review boards, conflict of interest committees, and investigators

Strategies for disclosing investigators' financial interests to potential research participants have been adopted by many research institutions. However, little is known about how decisions are made regarding disclosures of financial interests to potential research participants, including what is disclosed and the rationale for making these determinations. We sought to understand the attitudes, beliefs, and practices of institutional review board chairs, conflict of interest committee chairs, and investigators regarding disclosure of financial interests to potential research participants. Several themes emerged, including general attitudes toward conflicts of interest, circumstances in which financial interests should be disclosed, rationales and benefits of disclosure, what should be disclosed, negative effects of and barriers to disclosure, and timing and presentation of disclosure. Respondents cited several rationales for disclosure, including enabling informed decision making, promoting trust in researchers and research institutions, and reducing legal liability. There was general agreement that disclosure should happen early in the consent process. Respondents disagreed about whether to disclose the amounts of particular financial interests. Clarifying the goals of disclosure and understanding how potential research participants use the information will be critical in efforts to ensure the integrity of clinical research and to protect the rights and interests of participants.

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.

The contract research organization and the commercialization of scientific research

The early 1980s constituted a watershed in science, mainly concerning the extent and nature of globalization and commercialization of scientific research, and its impact upon the university. Considerable debate has arisen about the sources of this transition, but aside from a few lone voices, the scholarly literature has neglected the concurrent rise of the contract research organization (CRO) and its role int he commercialization of scientific research. The CRO warrants wider attention as a modern paradigm of privatized science in the biopharmaceutical sector. In discussing the CRO's technologies, the purposes they pursue, and the legal and policy initiatives that have fostered their rapid rise, we confront the wider implications of the modern regime of commercialized science for the future conduct of scientific research. We identify five areas of innovation: treatment of human subjects, control of disclosure, subjection of research tools to commercialization, redefinition of authorship, and re-engineering the goals of research.