"Caught In Each Other's Traps": Factors Perpetuating Incentive-Linked Prescribing Deals Between Physicians and the Pharmaceutical Industry

BACKGROUND

Despite known adverse impacts on patients and health systems, 'incentive-linked prescribing', which describes the prescribing of medicines that result in personal benefits for the prescriber, remains a widespread and hidden impediment to quality of healthcare. We investigated factors perpetuating incentive-linked prescribing among primary care physicians in for-profit practices (referred to as private doctors), using Pakistan as a case study.

METHODS

Our mixed-methods study synthesised insights from a survey of 419 systematically samples private doctors and 68 semi-structured interviews with private doctors (n=28), pharmaceutical sales representatives (n=12), and provincial and national policy actors (n=28). For the survey, we built a verified database of all registered private doctors within Karachi, Pakistan's most populous city, administered an electronic questionnaire in-person and descriptively analysed the data. Semi-structured interviews incorporated a vignette-based exercise and data was analysed using an interpretive approach.

RESULTS

Our survey showed that 90% of private doctors met pharmaceutical sales representatives weekly. Three interlinked factors perpetuating incentive-linked prescribing we identified were: gaps in understanding of conflicts of interest and loss of values among doctors; financial pressures on doctors operating in a (largely) privately financed health-system, exacerbated by competition with unqualified healthcare providers; and aggressive incentivisation by pharmaceutical companies, linked to low political will to regulate and an over-saturated pharmaceutical market.

CONCLUSION

Regular interactions between pharmaceutical companies and private doctors are normalised in our study setting, and progress on regulating these is hindered by the substantial role of incentive-linked prescribing in the financial success of physicians and the pharmaceutical industry employees. A first step towards addressing the entrenchment of incentive-linked prescribing may be to reduce opposition to restrictions on incentivisation of physicians from stakeholders within the pharmaceutical industry, physicians themselves, and policymakers concerned about curtailing growth of the pharmaceutical industry.

Cannabis industry campaign expenditures in Colorado, 2005-2021

BACKGROUND

The cannabis industry has been described using the commercial determinants of health framework because it seeks to increase sales and profits through efforts to change the political environment. To increase understanding of these cannabis industry's efforts, this study describes cannabis industry campaign contributions in Colorado through an analysis of public records.

METHODS

We reviewed datasets posted online at the Colorado Secretary of State's Transparent in Contribution and Expenditure Reporting (TRACER) Campaign Finance System. We generated descriptive data on cannabis industry contributions to elections and conducted regressions to identify predictors of contributions, and associations between lagged contributions and a legislator's cannabis industry score (how closely aligned lawmaker's legislative history is with the cannabis industry from -1 to 1).

RESULTS

Between 2005-2021, 429 cannabis-affiliated contributors gave $4,658,385 (2021 inflation-adjusted) to 512 electoral committees. Contributions came primarily from non-profits (45%), businesses (27%), and individuals (25%). After recreational legalization in 2012, contributions from non-profit donors with industry ties gave way to contributions from cannabis businesses, business owners, and lobbyists. Cannabis industry contributions to local and state-wide ballot initiative campaigns historically made up the majority of the industry spending, but contributions to candidate committees more than tripled between the 2009-2010 legislative cycle and the 2019-2020 cycle. From 2017-2020, every $10,000 in lagged campaign donations from cannabis industry affiliated contributors was associated with a 0.245-point increase in a legislator's cannabis industry score (p=0.04).

CONCLUSION

Cannabis-affiliated interests made substantial campaign contributions in Colorado. Public health advocates should monitor industry connections to lawmakers and industry tactics used to mask the source of political contributions. Continued surveillance of the cannabis industry is essential to exposing conflicts of interest and preventing undue industry influence.

Interactions Between Nutrition Professionals and Industry: A Scoping Review

BACKGROUND

In recent years, interactions between nutrition professionals (NPs) and the food industry, such as sponsorship arrangements, have raised concerns, particularly as these may negatively impact the trustworthiness and credibility of the nutrition profession. This study aimed to map the literature and identify knowledge gaps regarding interactions between NPs and industry. We sought to examine the nature of such interactions and NPs perspectives about these, as well as the risks and solutions.

METHODS

We conducted a scoping review according to a pre-registered protocol, searching eight electronic databases and grey literature sources in March 2021 to identify documents for inclusion. Two independent reviewers screened citations for inclusion and conducted data extraction. Quantitative and qualitative syntheses were conducted.

RESULTS

We identified 115 documents for analysis, published between 1980 to 2021, with a majority from the United States (n=59, 51%). Only 32% (n=37) were empirical studies. The food industry was the most frequent industry type discussed (n=91, 79%). We identified 32 types of interactions between NPs and industry, such as continuing education provided by industry and sponsorship of professional bodies and health and nutrition organizations. The financial survival of nutrition organizations and continuing education access for NPs were the most frequently cited advantages of industry-NPs interactions. On the other hand, undermining public trust, NPs credibility and public health nutrition recommendations were pointed out as risks of these interactions. Following a code of ethics, policies, or guidelines was the most frequently proposed solution for managing these interactions.

CONCLUSION

Despite the increasing attention given to this issue, few empirical papers have been published to date. There is a need for more research to better and systematically document industry interactions with NPs and the impacts associated with these, as well as more research on effective management strategies. Registry Name and Number: Interactions between nutrition professionals and industry actors: A scoping review protocol. doi:10.17605/OSF.IO/Q6PUA.

A Systematic Appraisal of Conflicts of Interest and Researcher Allegiance in Clinical Studies of Dry Needling for Musculoskeletal Pain Disorders

OBJECTIVE

The purpose of this study was to determine the frequency and methods of conflicts of interest (COI) reporting in published dry needling (DN) studies and to determine the frequency of researcher allegiance (RA).

METHODS

A pragmatic systematic search was undertaken to identify DN studies that were included in systematic reviews. Information regarding COI and RA were extracted from the full text of the published DN reports, and study authors were sent a survey inquiring about the presence of RA. A secondary analysis also was undertaken based on study quality/risk of bias scores that were extracted from the corresponding systematic reviews and study funding extracted from each DN study.

RESULTS

Sixteen systematic reviews were identified, containing 60 studies of DN for musculoskeletal pain disorders, 58 of which were randomized controlled trials. Of the DN studies, 53% had a COI statement. None of these studies disclosed a COI. Nineteen (32%) authors of DN studies responded to the survey. According to the RA survey, 100% of DN studies included at least 1 RA criterion. According to the data extraction, 1 RA criterion was met in 45% of the DN studies. The magnitude of RA per study was 7 times higher according to the surveys than in the published reports.

CONCLUSION

These results suggest that COI and RA might be underreported in studies of DN. In addition, authors of DN studies might be unaware of the potential influence of RA on study results and conclusions.

IMPACT

Improved reporting of COI/RA might improve credibility of results and help identify the various factors involved in complex interventions provided by physical therapists. Doing so could help optimize treatments for musculoskeletal pain disorders provided by physical therapists.

Tip of the Iceberg? Country- and Company-Level Analysis of Drug Company Payments for Research and Development in Europe

BACKGROUND

Creating new therapies often involves drug companies paying healthcare professionals and institutions for research and development (R&D) activities, including clinical trials. However, industry sponsorship can create conflicts of interest (COIs). We analysed approaches to drug company R&D payment disclosure in European countries and the distribution of R&D payments at the country and company level.

METHODS

Using documentary sources and a stakeholder survey we identified country- regulatory approaches to R&D payment disclosure. We reviewed company-level descriptions of disclosure practices in the United Kingdom, a country with a major role in Europe's R&D. We obtained country-level R&D payment data from industry trade groups and public authorities and company-level data from eurosfordocs.eu, a publicly available payments database. We conducted content analysis and descriptive statistical analysis.

RESULTS

In 32 of 37 studied countries, all R&D payments were reported without named recipients, following a self-regulatory approach developed by the industry. The methodological descriptions from 125 companies operating in the United Kingdom suggest that within the self-regulatory approach companies had much leeway in deciding what activities and payments were considered as R&D. In five countries, legislation mandated the disclosure of R&D payment recipients, but only in two were payments practically identifiable and analysable. In 17 countries with available data, R&D constituted 19%-82% of all payments reported, with self-regulation associated with higher shares. Available company-level data from three countries with self-regulation suggests that R&D payments were concentrated by big funders, and some companies reported all, or nearly all, payments as R&D.

CONCLUSION

The lack of full disclosure of R&D payments in countries with industry self-regulation leaves considerable sums of money unaccounted for and potentially many COIs undetected. Disclosure mandated by legislation exists in few countries and rarely enhances transparency practically. We recommend a unified European approach to R&D payment disclosure, including clear definitions and a centralised database.

Applying a Commercial Determinants of Health Lens to Understand, Expose and Counter Industry Co-option, Appeasement and Partnership Comment on "'Part of the Solution': Food Corporation Strategies for Regulatory Capture and Legitimacy"

Lacy-Nichols and Williams' examination of the food industry illustrates how it altered its approach from mostly oppositional to regulation to one of appeasement and co-option. This reflection builds upon this by using a commercial determinants of health (CDoH) lens to understand, expose and counter industry co-option, appeasement and partnership strategies that impact public health. Lessons learned from tobacco reveal how tobacco companies maintained public credibility by recruiting scientists to produce industry biased data, co-opting public health groups, gaining access to policy elites and sitting on important government regulatory bodies. Potential counter solutions to food industry appeasement and co-option include (i) understanding corporate actions of health harming industries, (ii) applying mechanisms to minimize industry engagement, (iii) dissecting industry relationship building, and (iv) exposing the negative effects of public private partnerships (PPPs). Such counter-solutions might help to neutralise harmful industry practices, products and policies which currently threaten to undermine healthy food policies.

Moral Lacunae in the Management of Dual Agency Dilemmas Comment on "Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations?"

Waitzberg and colleagues' participants articulate a wide range of strategies to manage tensions between clinical and economic obligations. There are, however, three notable absences in the data. First, all strategies described by participants are underpinned by the assumption that clinical (and associated administrative) practices need to either align with economic considerations or be made more compatible with them. Second, the dual agency dilemma was framed exclusively as existing at the level of the health care institution, with little attention paid to obligations to broader health systems. Third, there was no evidence of critical questioning of the priorities of the hospitals in which participants work. These absences do not render the strategies used by Weitzberg and colleagues' participants morally "wrong," but they do suggest that people who are deeply embedded in a system might fail to recognise the full range of moral concerns and moral possibilities.

Management of Conflicts of Interest in WHO's Consultative Processes on Global Alcohol Policy

BACKGROUND

The World Health Organization (WHO) has engaged in consultations with the alcohol industry in global alcohol policy development, including currently a draft action plan to strengthen implementation of the Global strategy to reduce the harmful use of alcohol. WHO's Framework for Engagement with Non-State Actors (FENSA) is an organization-wide policy that aims to manage potential conflicts of interest in WHO's interactions with private sector entities, non-governmental institutions, philanthropic foundations and academic institutions.

METHODS

We analysed the alignment of WHO's consultative processes with non-state actors on "the way forward" for alcohol policy and a global alcohol action plan with FENSA. We referred to publicly accessible WHO documents, including the Alcohol, Drugs and Addictive Behaviours Unit website, records of relevant meetings, and other documents relevant to FENSA. We documented submissions to two web-based consultations held in 2019 and 2020 by type of organization and links to the alcohol industry.

RESULTS

WHO's processes to conduct due diligence, risk assessment and risk management as required by FENSA appeared to be inadequate. Limited information was published on non-state actors, primarily the alcohol industry, that participated in the consultations, including their potential conflicts of interest. No minutes were published for WHO's virtual meeting with the alcohol industry, suggesting a lack of transparency. Organizations with known links to the tobacco industry participated in both web-based consultations, despite FENSA's principle of non-engagement with tobacco industry actors.

CONCLUSION

WHO's consultative processes have not been adequate to address conflicts of interest in relation to the alcohol industry, violating the principles of FENSA. Member states must ensure that WHO has the resources to implement and is held accountable for appropriate and consistent safeguards against industry interference in the development of global alcohol policy.

Conflict of Interest Policies at Medical Schools and Teaching Hospitals: A Systematic Review of Cross-sectional Studies

BACKGROUND

This systematic review aims to estimate the proportion of medical schools and teaching hospitals with conflicts of interest (COI) policies for health research and education, to describe the provisions included in the policies and their impact on research outputs and educational quality or content.

METHODS

Experimental and observational studies reporting at least one of the above mentioned aims were included irrespective of language, publication type or geographical setting. MEDLINE, Scopus, Embase and the Cochrane Methodology Register were searched from inception to March 2020. Methodological study quality was assessed using an amended version of the Joanna Briggs Institute's checklist for prevalence studies.

RESULTS

Twenty-two cross-sectional studies were included; all were conducted in high-income countries. Of these, 20 studies estimated the prevalence of COI policies, which ranged from 5% to 100% (median: 85%). Twenty studies assessed the provisions included in COI policies with different assessment methods. Of these, nine analysed the strength of the content of medical schools' COI policies using various assessment tools that looked at a range of policy domains. The mean standardised summary score of policy strength ranged from 2% to 73% (median: 30%), with a low score indicating a weak policy. North American institutions more frequently had COI policies and their content was rated as stronger than policies from European institutions. None of the included studies assessed the impact of COI policies on research outputs or educational quality or content.

CONCLUSION

Prevalence of COI policies at medical schools and teaching hospitals varied greatly in high-income countries. No studies estimated the prevalence of policies in low to middle-income countries. The content of COI policies varied widely and while most European institutions ranked poorly, in North America more medical schools had strong policies. No studies were identified on impact of COI policies on research outputs and educational quality or content.

Associations Between Aggregate NLP-Extracted Conflicts of Interest and Adverse Events by Drug Product

This study evaluates associations between aggregate conflicts of interest (COI) and drug safety. We used a machine-learning system to extract and classify COI from PubMed-indexed disclosure statements. Individual conflicts were classified as Type 1 (personal fees, travel, board memberships, and non-financial support), Type 2 (grants and research support), or Type 3 (stock ownership and industry employment). COI were aggregated by type compared to adverse events by product. Type 1 COI are associated with a 1.1-1.8% increase in the number of adverse events, serious events, hospitalizations, and deaths. Type 2 COI are associated with a 1.7-2% decrease in adverse events across severity levels. Type 3 COI are associated with an approximately 1% increase in adverse events, serious events, and hospitalizations, but have no significant association with adverse events resulting in death. The findings suggest that COI policies might be adapted to account the relative risks of different types of financial relationships.

Optimizing Ethics Engagement in Research: Learning from the Ethical Complexities of Studying Opioid Use in Pregnancy

Research on opioid use in pregnancy is critically important to understand how the opioid epidemic has affected a generation of children, but also raises significant ethical and legal challenges. Embedded ethicists can help to fill the gaps in ethics oversight for such research, but further guidance is needed to help strike the balance between integration and independence.

It Is Not Enough to Assess Conflicts of Interest When We Bring the Commercial Sector to the Policy Table Comment on "Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool"

Ralston et al offer us an interesting analysis of the consultation process of World Health Organization's (WHO's) "Draft approach on the prevention and management of conflicts of interests in the policy development and implementation of nutrition programs at country level," in which it shows us how the industry tries to frame the discussion in individual conflicts of interest, avoiding structural conflicts of interest. We must not forget other issues of importance in policy-making, such as the imbalance of power between different actors and the strategies of undue influence used by food and beverage corporations. It is essential to develop regulatory-based tools and procedures that embody ethics and good governance and that can be applied systematically and routinely to prevent corporate influence in health policy-making. A global observatory of corporate practices would also be needed to recommend to governments efficient actions to avoid corporate capture of their policies.

Industry Payments to Pain Medicine Physicians: An Analysis of the Centers for Medicare and Medicaid Services Open Payments Program

OBJECTIVE

To analyze industry payments to pain medicine physicians in the United States.

DESIGN

Retrospective cohort study using publicly available databases.

SUBJECTS

The study includes U.S. pain medicine physicians (PMPs) with reports in the Open Payments program from 2013 to 2018.

METHODS

The Centers for Medicare and Medicaid Services Open Payments program was analyzed for general, investment, and ownership payments to PMPs reported from 2013 to 2018. The nature, type, and geographic variation of payments were analyzed.

RESULTS

The main findings of the study are as follows: 1) Payments made to PMPs constituted a small proportion of the payments made to all physicians in the United States, and the number of transactions and the total dollar amount seem to have decreased from 2016 to 2018. 2) The median number of payments among physicians with reported payments was around 4 (interquartile range: 18), and the majority of them were under $20. 3) The majority of payments were for in-kind items and services (85%) and were made for food and beverages (91%), travel and lodging (5.5%). 4) Some of the ownership and investment interest payments exceeded $500,000. 5) The top five drugs associated with physician payments included medications with opioids. 6) A very small minority of payments were made for entertainment or gifts. 7) A third of PMPs with reports had payments reported under more than one taxonomy.

CONCLUSIONS

Overall payments made to PMPs seem to be decreasing since 2016. The majority of the payments are made for the food, beverage, and travel categories. Public and physician awareness of the Open Payments system reports is essential to promote transparency and to minimize adverse effects of financial relationships on patient care.

Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool

BACKGROUND

With multi-stakeholder approaches central to efforts to address global health challenges, debates around conflict of interest (COI) are increasingly prominent. The World Health Organization (WHO) recently developed a proposed tool to support member states in preventing and managing COI in nutrition policy. We analysed responses to an online consultation to explore how actors from across sectors understand COI and the ways in which they use this concept to frame the terms of commercial sector engagement in health governance.

METHODS

Submissions from 44 Member States, international organisations, non-governmental organizations (NGOs), academic institutions and commercial sector actors were coded using a thematic framework informed by framing theory. Respondents' orientation to the tool aligned with two broad frames, ie, a 'collaboration and partnership' frame that endorsed multi-stakeholder approaches and a 'restricted engagement' frame that highlighted core tensions between public health and food industry actors.

RESULTS

Responses to the WHO tool reflected contrasting conceptualisations of COI and implications for health governance. While most Member States, NGOs, and academic institutions strongly supported the tool, commercial sector organisations depicted it as inappropriate, unworkable and incompatible with the Sustainable Development Goals (SGDs). Commercial sector respondents advanced a narrow, individual-level understanding of COI, seen as adequately addressed by existing mechanisms for disclosure, and viewed the WHO tool as unduly restricting scope for private sector engagement in nutrition policy. In contrast, health-focused NGOs and several Member States drew on a more expansive understanding of COI that recognised scope for wider tensions between public health goals and commercial interests and associated governance challenges. These submissions mostly welcomed the tool as an innovative approach to preventing and managing such conflicts, although some NGOs sought broader exclusion of corporate actors from policy engagement.

CONCLUSION

Submissions on the WHO tool illustrate how contrasting positions on COI are central to understanding broader debates in nutrition policy and across global health governance. Effective health governance requires greater understanding of how COI can be conceptualised and managed amid high levels of contestation on policy engagement with commercial sector actors. This requires both ongoing innovation in governance tools and more extensive conceptual and empirical research.

Understanding professional stakeholders' active resistance to guideline implementation: The case of Canadian breast screening guidelines

Health guidelines aim to improve patient outcomes through the promotion of evidence-based practice. Yet, when a guideline's recommendations significantly differ from, or threaten the interests, values and preferred practices of end-users, organised and often very public resistance to guideline implementation may result. To explore this phenomenon, we theorise a case study consisting of the public discourse following the update to a primary care breast screening guideline in Canada in 2018. Informed by sociological perspectives on the professions and evidence-based medicine, this paper aims to explore: [1] why professional stakeholders form active resistances to the implementation of some clinical guidelines; and, [2] how professional values, perspectives, interests and/or experiences influence the stakeholders' stance. Current understandings have taken a reductive approach in conceptualising the exclusion of experts and their resistance as "conflict of interest." Rather, we suggest that resistance is the product of multiple areas of contention, stemming from tensions related to clinical and professional autonomy, medical jurisdiction, and the role of medical elites. We highlight considerations for future guideline development and implementation process changes to mitigate and resolve issues related to active resistance. These considerations include understanding resistance as a political strategy, increasing transparency of public input and coalition building as a part of the public response to active resistance.

Conflict of Interest in Nutrition: Where's the Power? Comment on "Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool"

Actual or perceived conflict of interests (COIs) among public and private actors in the field of nutrition must be managed. Ralston et al expose sharply contrasting views on the new World Health Organization (WHO) COI management tool, highlighting the contested nature of global debates. Both the WHO COI tool and the Ralston et al paper are largely quiet on aspects of power among different actors, however, which we argue is integral to these conflicts. We suggest that power needs to be acknowledged as a factor in COI; that it needs to be systematically assessed in COI tools using approaches we outline here; and that it needs to be explicitly addressed through COI mechanisms. We would recommend that all actors in the nutrition space (not only private companies) are held to the same COI standards, and we would welcome further studies such as Ralston et al to further build accountability.

Should Public Health and Policy Communities Interact With the Food Industry? It Depends on Context Comment on "Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool"

The issue of public health and policy communities engaging with food sector companies has long caused tension and debate. Ralston and colleagues’ article ‘Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool’ further examines this issue. They found widespread food industry opposition, not just to the details of the World Health Organization (WHO) tool, but to the very idea of it. In this commentary we reflect on this finding and the arguments for and against interacting with the food industry during different stages of the policy process. While involving the food industry in certain aspects of the policy process without favouring their business goals may seem like an intractable problem, we believe there are opportunities for progress that do not compromise our values as public health professionals. We suggest three key steps to making progress.

Purveyors of the Commercial Determinants of Health Have No Place at Any Policy Table Comment on "Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool"

With public health attention on the commercial determinants of health showing little sign of abatement, how to manage conflicts of interest (COI) in regulatory policy discussions with corporate actors responsible for these determinants is gaining critical traction. The contribution by Ralston et al explores how COI management has itself become a terrain of contestation in their analysis of submissions on a draft World Health Organization (WHO) tool to manage COI conflicts in development of nutrition policy. The authors identify two camps in conflict with one another: a corporate side emphasizing their individual good intents and contributions, and an non-governmental organization (NGO) side maintaining inherent structural conflicts that require careful proscribing. The study concludes that the draft tool does a reasonable job in ensuring COI are avoided and policy development sheltered from corporate self-interests, introducing novel improvements in global governance for health. At the same time, the tool appears to adhere to a belief that private economic (corporate) and public good (citizen) conflicts can indeed be managed. I question this assumption and posit that public health needs to be much bolder in its critique of the nature of power, influence, and self-interests that pervade and risk dominating our stakeholder models of global governance.

Tackling NCDs: The Need to Address Alcohol Industry Interference and Policy Incoherence Across Sectors Comment on "Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool"

Ralston et al highlight the ways that different actors in global nutrition governance conceptualise and frame the role of non-state actors in governance arrangements, including the potential for conflict of interest (COI) to undermine global health efforts. The authors argue that the World Health Organization (WHO) draft tool on managing COI in nutrition policy is an important innovation in global health, but that further research and refinement is needed for operationalising the management of COI with diverse actors in diverse contexts. In this commentary, reflecting on strategic framing and industry interference in policy-making, we argue for the urgent need for states and intergovernmental organisations to prevent alcohol industry interference in the development of national and global alcohol policy. We argue that policy incoherence remains a key barrier, where governments pursue health goals in the health sector while pursuing exports and market liberalisation of health harmful commodities in the trade sector.

"Conflicted" Conceptions of Conflict of Interest: How the Commercial Sector Responses to the WHO Tool on Conflict of Interest in Nutrition Policy Are Part of Their Standard Playbook to Undermine Public Health Comment on "Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool"

Managing conflict of interest (CoI) among the interested stake-holders in nutrition policy is a vexed and controversial issue. This commentary builds on Ralston and colleagues' highly informative analysis of the 44 submissions to the World Health Organization (WHO) draft tool on preventing and managing CoI in national nutrition programs. The commentary proposes that the commercial sector actors are, by definition, too conflicted to objectively respond to the draft tool. The responses of the commercial sectors are predictable, as they mimic their positions during the prior negotiation for the development of the Framework for Engagement of Non-State Actors (FENSA). Their overall approach, and specific responses, are typical of the now standard methods of the ultra-processed food and beverage industry's 'corporate playbook.' In addition, Ralston et al's analysis raises a number of other issues, such as: why these corporations are so keen to be included in the world of multi-stakeholder partnerships, why so few member states responded to the draft tool, and problems with the term 'private sector.' The commentary ends with a suggestion for WHO to seek broader involvement from the 160+ member states who have yet to participate in the consultations regarding the draft tool.

[Financial contributions to guideline group members from industry: An analysis based on the US Open Payments database]

INTRODUCTION

Evidence-based clinical practice guidelines are one of the most important sources to inform clinical decision-making. They contain recommendations to support treatment decisions. These recommendations should be free from bias and should only aim to increase patient benefit. To ensure this, recommendations should be free from bias caused by conflicts of interest. When conflicts of interest exist, they should be completely transparent. The aim of this study was to analyze the payments from pharmaceutical and medical device industry to clinical practice guideline panel members (GPM). In addition, we assessed the completeness and accuracy of the GPMs' conflict of interest statements.

METHODS

A manual search for international guidelines was conducted on the website of the National Guideline Clearinghouse. We included all available clinical practice guidelines published in 2017. We extracted the names of all guideline group members and identified the payments they had received from industry over the four years preceding the publication using the "open payments" database.

RESULTS

In total, 81 guidelines were identified. We found data on payments for 543 out of 659 GPMs. For 34% of the GPMs, there was no declaration of individual conflicts of interest in either the guideline or related documents. The sum of payments across all guidelines to all GPMs was 10,844,938 USD. The average payment amounted to 19,972 USD and the median 1,227 USD. Sixty two percent of GPMs received at least 500 USD. Of these, 17% stated that they had no conflict of interest to declare.

DISCUSSION

The amount of industrial payments in some subject areas raises doubt about the independence of guideline recommendations. Stricter rules are needed to avoid and manage conflicts of interest of guideline authors. The analysis carried out indicates that conflict of interest involving GPMs is a considerable problem.

CONCLUSION

GPMs receive sizeable payments from industry. The payments are often inadequately disclosed or not disclosed at all. This threatens the objectivity of the recommendations in clinical practice guidelines.

In the Era of Social Media: Is it time to establish a code of online ethical conduct for healthcare professionals?

Social media is becoming an invasive part of the lives of many professionals including those in the healthcare field. One of the countless implications of such an invasion is how the healthcare professional's engagement with social media affects the traditional doctor-patient relationship. The online presence of professionals should be carefully self-monitored as it affects the individual's reputation and society's perception of their profession. Therefore, the contents of public and personal accounts must differ according to their purpose. In the public eye, conflicts of interest must be declared and scientifically-based medical advice should be clearly differentiated from experience-based advice, personal opinions or commercial advertisements. Online doctor-patient relationships risk the privacy of patients as well as the personal privacy of the healthcare professional. Personal accounts created for friends and family should be kept separate from public accounts created for educational, professional or commercial purposes. Published educational material should be clearly differentiated from commercial material so that it is easier for the public to make an informed decision. This paper proposes a code of online ethical conduct to be implemented in Oman.

Addressing NCDs: Penetration of the Producers of Hazardous Products into Global Health Environment Requires a Strong Response Comment on "Addressing NCDs: Challenges From Industry Market Promotion and Interferences"

Timely warnings and examples of industry interference in relation to tobacco, alcohol, food and breast milk substitutes are given in the editorial by Tangcharoensathien et al. Such interference is rife at national levels and also at the global level. In an era of ‘private public partnerships’ the alcohol and food industries have succeeded in insinuating themselves into the global health environment and their influence is seen in key recommendations regarding non-communicable disease (NCD) risk factors in United Nations (UN) reports. The absence of legally binding health treaties in these areas facilitates this industry engagement and the Framework Convention on Tobacco Control provides a valuable model to apply to control of other hazardous products.

[The dissemination of knowledge]

Writing content regarding the progress of medical knowledge demands the adherence to recommended practices in scientific research. It also requires clear communication, choosing the most fitting journal for its review, and observing author’s instructions in order to enable its publication.

Everything You Need to Know About Peer Review - The Good, The Bad and The Ugly

Embarking on conducting peer reviews for academic journals can present a new and exciting challenge for early career researchers. This article offers succinct guidance about peer review: not only "what to do" (the Good) but also "what not to do" (the Bad) and "what to never do" (the Ugly). It outlines models of peer review and provides an overview of types of reviewer bias, including conflict of interest. More recent developments in journal peer review, such as author-suggested reviewers as well as manipulation of the peer review process are also discussed. A new position of Editorial Fellow at Heart, Lung and Circulation will provide aspiring researchers the opportunity for multi-faceted involvement with peer review at the Journal.

Corrigendum: Predicting spirometry readings using cough sound features and regression (2018 Physiol. Meas. 39 095001)

The purpose of this submission is to provide missing information to complete the conflict of interest statement associated with the article. The statements provided here augment the already provided information rather than replace it.

Letter to the Editor: More on Conflict of Interest Disclosure in a Top-Tier Portuguese Medical Journal

Not Applicable.

Reporting of Financial and Non-financial Conflicts of Interest in Systematic Reviews on Health Policy and Systems Research: A Cross Sectional Survey

Background: Systematic reviews are increasingly used to inform health policy-making. The conflicts of interest (COI) of the authors of systematic reviews may bias their results and influence their conclusions. This may in turn lead to misguided public policies and systems level decisions. In order to mitigate the adverse impact of COI, scientific journals require authors to disclose their COIs. The objective of this study was to assess the frequency and different types of COI that authors of systematic reviews on health policy and systems research (HSPR) report.

Methods: We conducted a cross sectional survey. We searched the Health Systems Evidence (HSE) database of McMaster Health Forum for systematic reviews published in 2015. We extracted information regarding the characteristics of the systematic reviews and the associated COI disclosures. We conducted descriptive analyses.

Results: Eighty percent of systematic reviews included authors’ COI disclosures. Of the 160 systematic reviews that included COI disclosures, 15% had at least one author reporting at least one type of COI. The two most frequently reported types of COI were individual financial COI and individual scholarly COI (11% and 4% respectively). Institutional COIs were less commonly reported than individual COIs (3% and 15% respectively) and non-financial COIs were less commonly reported than financial COIs (6% and 14% respectively). Only one systematic review reported the COI disclosure by editors, and none reported disclosure by peer reviewers. All COI disclosures were in the form of a narrative statement in the main document and none in an online document.

Conclusion: A fifth of systematic reviews in HPSR do not include a COI disclosure statement, highlighting the need for journals to strengthen and/or better implement their COI disclosure policies. While only 15% of identified disclosure statements report any COI, it is not clear whether this indicates a low frequency of COI versus an underreporting of COI, or both.

Sunshine Policies and Murky Shadows in Europe: Disclosure of Pharmaceutical Industry Payments to Health Professionals in Nine European Countries

Relationships between health professionals and pharmaceutical manufacturers can unduly influence clinical practice. These relationships are the focus of global transparency efforts, including in Europe. We conducted a descriptive content analysis of the transparency provisions implemented by February 2017 in nine European Union (EU) countries concerning payments to health professionals, with duplicate independent coding of all data. Using an author-generated, semi-structured questionnaire, we collected information from each disclosure policy/code on: target industries, categories of healthcare professionals covered, scope of payments included, location and searchability of the disclosed data. Our analysis shows that although important improvements have been put in place in the past few years, significant gaps remain in disclosure requirements and their implementation. The situation differs substantially from country to country and the most striking differences are between governmental and self-regulatory approaches, especially with regard to the comprehensiveness of the disclosed data. In many cases, individuals can still opt out and reporting is incomplete, with common influential gifts such as food and drink excluded. Finally, in several countries data are only available as separate PDFs from companies, thus making the payment reports difficult to access and analyse. In order to overcome these gaps, minimum standards for disclosures should be implemented across Europe. All payments to healthcare professionals and organizations should be included, all health-related industries should be required to submit reports, and usability of disclosed data should be guaranteed.

Towards Patient-Centered Conflicts of Interest Policy

Financial conflicts of interest exist between industry and physicians, and these relationships have the power to influence physicians' medical practice. Transparency about conflicts matters for ensuring adequate informed consent, controlling healthcare expenditure, and encouraging physicians' reflection on professionalism. The US Centers for Medicare & Medicaid Services (CMS) launched the Open Payments Program (OPP) to publicly disclose and bring transparency to the relationships between industry and physicians in the United States. We set out to explore user awareness of the database and the ease of accessibility to disclosed information, however, as we show, both awareness and actual use are very low. Two practical policies can greatly enhance its intended function and help alleviate ethical tension. The first is to provide data for individual physicians not merely in absolute terms, but in meaningful context, that is, in relation to the zip code, city, and state averages. The second increases access to the OPP dataset by adding hyperlinks from physicians' professional websites directly to their Open Payments disclosure pages. These changes considerably improve transparency and the utility of available data, and can furthermore enhance professionalism and accountability by encouraging physicians to reflect more actively on their own practices.

Conflict of Interest Disclosure in a Top-Tier Portuguese Medical Journal

INTRODUCTION

Scientific medical publications are considered to be a source of unbiased and independent information. Authors are required to disclose relationships with the pharmaceutical industry for transparency purposes. The aim of this work was to assess conflict of interest disclosure in a Portuguese top-tier medical journal by comparing authors' self-reported conflicts of interest with payments listed in the official database of Portuguese Ministry of Health.

MATERIAL AND METHODS

All articles published in the Portuguese Journal of Cardiology from December 2015 to May 2016 were reviewed. Articles based on clinical images, with authors affiliated to foreign institutions, editorials, letters to the editor, or submitted before January 1st 2015 were excluded. Authors were categorized on concordance between self-reported disclosures and payments listed in the database. Authors who authored multiple articles were counted as new authors, since each paper offered a new opportunity for financial disclosure.

RESULTS

Of the 155 authors surveyed, 82 (53%) were in perfect concordance with the sunshine database, while 73 authors (47%) had one or more undisclosed payments. Undisclosed payments totaled over € 210 000. Four (17%) articles mentioned a conflict of interest, 24 articles (96%) had at least one author with undisclosed payments.

DISCUSSION

None of the payments listed in the database was acknowledged in self-reported conflicts of interest. This might indicate that authors do not consider their financial relationships with the industry to be relevant.

CONCLUSION

The lack of concordance between self-reported conflicts of interest and payments found in the database raises concerns about incomplete disclosure.

Conflicts of Interest in Medicine. A Systematic Review of Published and Scientifically evaluated Curricula

Objective: Conflicts of interests resulting from interactions with pharmaceutical companies are pervasive in medicine and can result in an undue influence on physicians' decision-making. The objective of this systematic review is to analyze published and scientifically evaluated curricula for medical students and residents regarding such conflicts of interest. We begin by describing the covered topics and teaching methods; afterwards we analyze the quality of the curricula using the published data on their evaluations and comparing the content with content recommended for such curricula. Methods: We searched Pubmed, PsycInfo, EMBASE, OECD, WISO, SOWI and googlescholar up to and including the 5th of September 2016. Publications describing curricula for residents or medical students on the topic of conflicts of interest in medicine and evaluating them for their effects on the participants' learning were included. We analyzed the covered topics and the teaching methods used and compared them with recommendations by the American Medical Students' Association (AMSA) and Health Action International (HAI). Results: The literature search resulted in 20 publications that fulfilled our search criteria. In five trials, a control group was used, in no trial the participants were randomized to intervention or control group. 16/20 published curricula primarily covered marketing strategies by pharmaceutical companies, especially the interaction with pharmaceutical sales representatives (PSRs). Most curricula only covered a limited number of topics recommended by AMSA/HAI. The most frequent teaching method was a group discussion, which was used in 18/20 curricula; all curricula used at least one interactive teaching method. The evaluation of the curricula was heterogeneous in results as well as design. Some publications described a change of attitudes toward a stronger skepticism regarding interactions with pharmaceutical companies. Four publications described improved knowledge, one publication described a change in behavior toward a reduction of the acceptance of gifts. Conclusion: The trials conducted to this date regarding curricula on conflicts of interests are methodologically flawed and the described curricula lack important topics beyond marketing strategies of pharmaceutical companies. In addition, there are no data so far on the sustainability of the courses' effects on participants' behavior. It is therefore necessary to develop a model curriculum that covers a broader variety of topics and to evaluate it using a well thought-out methodology to create a foundation for the further improvement of teaching conflicts of interest in medicine.

Public Health Ethics and Conflict of Interests

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Bradford's law, the long tail principle, and transparency in Journal Impact Factor calculations

Beyond the commonly mentioned limitations of the Journal Impact Factor, we discuss the obsolete principle of selecting journals to create a fake-representative sample of ‘journals that matter’ and the opacity around the calculation and listing of Impact Factors. We use the example of Pharmacy Practice: in 2015 for illustration. We hypothesize that a business-oriented system of measuring the science and quality of scholarly journals may not be the best option to avoid biases and conflicts of interest.

Promoting Education Regarding Conflict of Interest Management

Even among highly educated health professionals, there is inconsistency in the knowledge and perception concerning both conflict of interest (COI) itself and COI disclosure. The key issue is the credibility of the manuscript, which relies heavily on transparency of COI for the reader. The tendency to disregard the importance of COI disclosure among journal editors has been recently highlighted. For all types of COI, the primary question is how it is managed. To ensure the enforcement of the declared journal COI policies, it is crucial that not only authors, but also those who are involved in the assessment of manuscripts, be educated and informed of the updated guidelines concerning COI disclosure.

Current levels of conflict of interest disclosure in medical publications from Korea

Medical research should be fully transparent. The aims of this study were to determine the prevalence of author-related conflict of interest (COI) policies and evaluate the actual state of COI disclosure in Korean medical journals. To determine the prevalence of author-related COI policies, we examined the 198 medical journals listed in the KoreaMed database. To investigate the actual state of COI disclosures in published papers, we analyzed the publications in a representative medical journal, the Journal of the Korean Medical Science, from the perspective of the relevance of the ethics of COI disclosure. A total of 164 (82.8%) journals required an author's statement of COI as a criterion for publication. Of these 164, most of them focused on financial COI, with 101 (61.6%) presenting the information related to COI disclosures as a separate paragraph with a clear title. We identified 114 articles published by the Journal of the Korean Medical Science over a seven-year period, from January, 2006 to December, 2012. Of these, 65 papers (57%) included an author's statement of COI. We found that the policies of Korean medical journals regarding the disclosure of author COIs are still behind the internationally suggested level.

Physician payment disclosure under health care reform: will the sun shine?

Pharmaceutical marketing has become a mainstay in U.S. health care delivery and traditionally has been directed toward physicians. In an attempt to address potential undue influence of industry and conflicts of interest that arise, states and the recently upheld health care reform act have passed transparency, or "sunshine," laws requiring disclosure of industry payments to physicians. The Centers for Medicare & Medicaid Services recently announced the final rule for the Sunshine Provisions as part of the reform act. However, the future effectiveness of these provisions are questionable and may be limited given the changing landscape of pharmaceutical marketing away from physician detailing to other forms of promotion. To address this changing paradigm, more proactive policy solutions will be necessary to ensure adequate and ethical regulation of pharmaceutical promotion.

Breaking up is hard to do: lessons learned from a pharma-free practice transformation

BACKGROUND

Academic medical centers are examining relationships with the pharmaceutical industry and making changes to limit interactions. Most doctors, however, practice outside of academic institutions and see pharmaceutical detailers and accept drug samples and gifts. Little guidance for practicing physicians exists about transforming practices to become pharma-free. Consideration must be given to the impact on practice culture, staff views, and patient needs.

METHODS

A small private practice, setting out to transform into a pharma-free clinic, used a practice transformation process that examined the industry presence in the clinic, educated the doctors on potential conflicts of interest, and improved practice flow. Staff were given the opportunity to share concerns, and their issues were acknowledged. Educational interventions were developed to help providers keep current. Finally, efforts were made to educate patients about the policy.

RESULTS

The clinic recorded the degree to which it was detailed. Loss of gifts, keeping current with new drugs, and managing without samples were noted concerns. Policy change champions developed strategies to address concerns.

DISCUSSION

A shift in practice culture to a pharma-free clinic is achievable and maintainable over time. Barriers to success can be identified and overcome with attention given to careful gathering of information, staff input, and stakeholder education.

Managing conflicts of interest in continuing medical education: a comparison of policies

BACKGROUND

Altruism is a central underpinning of professional behavior; however physicians may face instances in which their secondary (financial) interest is in competition with their primary (patient health, research integrity, professional education) interests. Most medical institutions have developed policies to manage conflicts of interest, but chiropractic institutions, organizations and providers may not be well-acquainted with such policies.

PURPOSE

To compare the policies of the Department of Veterans Affairs (VA) and the North American Spine Society (NASS) regarding management of conflicts of interest in continuing medical education (CME).

METHODS

A qualitative review of published policies of the VA and NASS was performed. The policies of each organization were retrieved and reviewed, and data were entered into a spreadsheet for comparison. Content experts at each organization were contacted to provide additional information.

RESULTS

The VA and NASS provide explicit, similar policies to manage conflicts of interest in CME. Proposed speakers are required to disclose the nature and value of financial relationships relevant to content of their planned talk/presentation. Procedures for committee review, mitigation of conflict, or prohibiting the participation of a given speaker have been described. Disclosure must be made to the attendees of an educational activity in printed materials and at the time of presentation.

CONCLUSION

The VA and NASS appear similar in their policies to manage conflicts of interest in CME. The policies of the VA and NASS may provide examples for the chiropractic profession to consider in relation to chiropractic continuing education.

Editorial independence in the electronic age: new threats, old owners?

Editorial independence is crucial for the intellectual life of a scientific journal. A journal exists only as an idea created by authors and readers, with some editorial orchestration. Editorial independence can be compromised by pressure put on editors by their owners-whether commercial publishers or professional organizations. Both types of owners rely heavily on income from paid advertising in their print journals. Yet, the massive expansion of journal readership that has resulted due to the development of the Web has effected a marked shift in the readership of the journal, both geographically and intellectually, producing a new community of users who see only electronic versions of the journal. Commercial pressures on owners to satisfy the interests of the (mainly national and professional) print readership conflict with the editorial independence needed to respond to the vast Web constituency. This is a major source for compromise of editorial independence. Reduction of commercial pressures by transferring editorial costs to authors and by other cost-reducing models are discussed in this article.

Medicine and money: friends or foe?

The relationship between medicine and money is a delicate one that all people involved need to handle responsibly. If one becomes a physician for the mere fact of pursuing money, s/he may soon find that another profession or activity may have fulfilled such a need in a better way. While in the practice of medicine the interest of the patient is paramount, this does not suggest that the welfare of the physician should be neglected at all. It is much about a balance of priorities between the legal and ethical pursuit of money and the promotion of the health of society. Physicians are not called to a life of self-denial, poverty and destitution, as others may be tempted to suggest. The service of patients and the honest reward from one's labour are not incompatible. Where conflict of interest arises, it is prudent for a physician to always remember never to harm oneself, the profession and the patient more than what can be gained.