Competing interests by benbenzhou

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									Competing interests
  Jaideep A Gogtay MD

  Conflict of Interest
  Employee of Cipla Ltd
Appetite suppressant drugs and the risk of
    primary pulmonary hypertension
                  OR:23.1 (6.9-77.7)   Although physicians and
                                       patients need to be informed,
                                       the possible risk of pulmonary
                                       hypertension associated with
                                       dexfenfluramine is small and
                                       appears to be outweighed
                                       by benefits when the drug is
                                       used appropriately.




NEJM 1996;35:609-16                               NEJM 1996;335:659-660
  What does competing (conflict of)
          interest mean?

• Set of conditions in which professional
  judgment concerning a primary interest
  (e.g. patient’s welfare or validity of
  research)
• tends to be unduly influenced by a
  secondary gain (e.g. financial gain)

     Condition, not behaviour
     Who has competing interests?
•   Physicians
•   Scientists/Resarchers
•   Teachers/Scholars
•   Reviewers
•   Editors
•   Conflicts of interest are universal
             Professional interests
Profession      1o interest        2o interest

Physician       Patient care      Monetary, Prestige

Researcher       Generation         Publication
                of knowledge        and funding

Companies         New therapies     Trust
                  Monetary         Acceptance

Journals        Dissemination     Impact factor
                of authentic      Subscription
                 information
             Professional interests
Profession      1o interest        2o interest

Physician       Patient care      Monetary, Prestige

Researcher       Generation         Publication
                of knowledge        and funding

Companies         New therapies     Trust
                  Monetary         Acceptance

Journals        Dissemination     Impact factor
                of authentic      Subscription
                 information
  Conflicts of interest are universal
• Doctors
  –   Investigations
  –   Admission to a particular hospital
  –   Carry out treatments (drugs, procedures)
  –   Own a hospital
• Doctors and Pharmaceutical/Biotechnology
  companies
  – Paid consultants to a company
  – Received research grants/travel grants
  – There are very few doctors who have not been
    given anything by a pharmaceutical company
Conflict of interest in the debate over
 calcium channel antagonists and MI




                                NEJM 1998;338:101-106
JAMA 1998;279:1566-70
       Conflicts of interest are universal
• Scientists
   – Idea/Patents
• Journals
   – Reprints e.g. VIGOR study showed that Rofecoxib had less
     GI adverse events; 1 million reprints purchased by the
     sponsor (profits of 600,000 USD)
   – Advertisement revenue
• Personal (non-financial)
   – Relationships with individuals involved in submission of a
     paper (Friend, spouse, ex-boss/mentor, adversary)
   – Convictions (religious, political, ideological or other)
      • Opposed to emergency contraception
          Declaration of interest


Nicholas Wald and Malcolm Law have
patents for the Polypill (in EU countries and
pending in USA and Canada. Priority date 10
April 2000)
       Conflicts of interest are universal
• Scientists
   – Idea/Patents
• Journals
   – Reprints e.g. VIGOR study showed that Rofecoxib had less
     GI adverse events; 1 million reprints purchased by the
     sponsor (profits of 600,000 USD)
   – Advertisement revenue
• Personal (non-financial)
   – Relationships with individuals involved in submission of a
     paper (Friend, spouse, ex-boss/mentor, adversary)
   – Convictions (religious, political, ideological or other)
      • Opposed to emergency contraception
       Conflicts of interest are universal
• Scientists
   – Idea/Patents
• Journals
   – Reprints e.g. VIGOR study showed that Rofecoxib had less
     GI adverse events; 1 million reprints purchased by the
     sponsor (profits of 600,000 USD)
   – Advertisement revenue
• Personal (non-financial)
   – Relationships with individuals involved in submission of a
     paper (Friend, spouse, ex-boss/mentor, adversary)
   – Convictions (religious, political, ideological or other)
      • Emergency contraception
              Is it a bad thing?
• Conflict of interest per se is not intrinsically
  bad
• Represent situations in which interests of
  partners may not fully overlap
• Not judging moral character
Conflicts of interest need to be
regulated (not self regulation)
                    Critics
• Questions their ‘scientific integrity’
• Physicians say that decisions about patient
  care are not influenced by financial incentives
• Unfairly punish ethical physicians and
  researchers for the misdeeds of a few
     Purposes of regulations regarding
            conflict of interest
• Maintain integrity of professional judgment
  – Minimize the influence of secondary interests
• Maintain confidence in professional judgment
  – People should continue to have faith in decisions
  – Distrust of the profession
• Failure to avoid conflict of interest may be
  wrong even when one is not influenced by
  secondary interests
The most important health-care                 This new "medical-industrial
development of the day is the recent,          complex" may be more efficient
relatively unheralded rise of a huge           than its nonprofit competition,
new industry that supplies health-care         but it creates the problems of
services for profit.                           overuse and fragmentation of
• Hospitals and nursing homes,                 services, overemphasis on
• Diagnostic laboratories,                     technology, and "cream-
• Home-care and emergency-room                 skimming," and it may also
services,                                      exercise undue influence on
• Dialysis                                     national health policy.


                        In this medical market, physicians
                        must act as discerning purchasing
                        agents for their patients and
                        therefore should have no
                        conflicting financial interests.

 NEJM 1980;303:963-70
                Conclusions???
• Almost inevitable
• Full disclosure: Financial/non financial
  – Authors
  – Reviewers
  – Editors
• Evidence based medicine
  – Quality and level of evidence

								
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