Transcript Academic medicine . . . Finds itself struggling to create

The Academic-Industry Relationship
The CAGE Questionnaire
for Drug Company Dependence
• Have you ever prescribed Celebrex ?
TM
• Do you get Annoyed by people who complain about drug
lunches and free gifts?
• Is there a medication loGo on the pen you're using right
now?
• Do you drink your morning Eye-opener out of a Lipitor
coffee mug?
TM
If you answered yes to 2 or more of the above, you may be drug
company-dependent.
The Modified CAGE Questionnaire
for Drug Company Dependence
• Have you ever been involved in a clinical trial of Celebrex ?
TM
• Do you get Annoyed when drug companies try to prevent you
from publishing your results?
• Do you feel guilty when someone else Ghostwrites an article
and puts your name on it?
• Do you drink your morning Eye-opener out of a Lipitor
coffee mug?
TM
If you answered yes to 2 or more of the above, you may be drug
company-dependent.
Fiction
“You are again reminded that under the confidentiality
clause in your contract you are expressly forbidden to
impart this misinformation to your patients . . . You are
formally warned against any further dissemination,
verbally or by any other means, of these inaccurate and
malicious opinions based on the false interpretations of
data obtained while you were under contract to Messrs.
Karel Vita Hudson . . .”
---Letter to Dr. Lara Emrich from the law firm
representing KVH. (From The Constant Gardener)
Truth
“As you know, paragraph 7 of the LA-02 Contract
provides that all information whether written or not,
obtained or generated by you during the term of the LA02 Contract and for a period of three years thereafter,
shall be and remain secret and confidential and shall not
be disclosed in any manner to any third party except with
the prior written consent of Apotex. Please be aware that
Apotex will take all possible steps to ensure that these
obligations of confidentiality are met and will vigorously
pursue all legal remedies in the event that there is any
breach of these obligations.”
--Excerpt from a letter dated May 24, 1996, from Dr. Michael
Spino, Vice President of Scientific Affairs, Apotex Research Inc., to
Dr. Nancy Olivieri.
Withholding research results in academic
life science
• Survey of 3,394 life science faculty at 50 U.S.
universities.
• 410 (19.8%) reported delays in publishing
research results of > 6 months.
JAMA 1997;277:1224
Withholding research results in academic life
science
Reasons for delays in publishing
100%
80%
60%
46%
33%
40%
28%
26%
20%
0%
Allow time for
patent
application
JAMA 1997;277:1224
Protect
financial
value of
results
Delay
Allow time for
dissemination
license
of undesired
agreement
results
Withholding research results in academic
genetics
• Survey of 3,000 life science faculty at 100 U.S.
universities
• 64% responded. 1,240 geneticists
• 47% of geneticists had been denied requests
for information or data within the preceding
3 years.
• 12% had denied others’ requests for data in
the preceding 3 years.
JAMA 2002;287:473
Withholding research results in academic genetics
Reasons for withholding information, data, or materials
100%
80%
80%
60%
45%
40%
27%
23%
21%
20%
0%
Effort required
Cost of
providing
materials
JAMA 2002;287:473
Need to honor
Patient
requirements confidentiality
of industry
sponsor
Need to
protect
commercial
value of
results
Effects of the relationship on:
•
•
•
•
•
Research agenda
Research design
Research results
Research authorship (ghost writing)
Research publication (or withholding)
Industry funding and results of clinical trials
Scope and Impact of Financial Conflicts of
Interest in Biomedical Research
• Systematic review of studies on relationships
between investigators and industry.
• 144 studies identified in Medline and other
sources.
• 37 studies met inclusion criteria.
JAMA 2003;289:454
Scope and Impact of Financial Conflicts of
Interest in Biomedical Research
JAMA 2003;289:454
Pharmaceutical industry sponsorship and
research outcome and quality: systematic
review
• Systematic review of studies that compared
pharmaceutical company-sponsored research to
non-industry-sponsored research.
• Searched Medline, Embase, Cochrane register;
contacted experts.
• 30 studies were included in analysis.
BMJ 2003;326:1167-1170
Pharmaceutical industry sponsorship and
research outcome and quality: systematic
review
• Drug company-sponsored research was less likely to be
published than research sponsored by other sources.
• Drug company sponsored Pharmacoeconomic studies were
more likely to report results favoring the sponsor's product
than studies with other sponsors.
• 13 of 16 studies found that clinical trials and meta-analyses
sponsored by drug companies favored the sponsor’s product.
• Methodological quality of industry-sponsored studies was as
good as or better than non-industry sponsored studies.
BMJ 2003;326:1167-1170
Association of Funding and Conclusions in Randomized
Drug Trials: A Reflection of Treatment Effect of Adverse
Events?
• Meta-analyses of randomized trials from a random sample
of Cochrane reviews.
• 25 reviews comprising 370 trials included in analysis.
• Funding sources were classified as nonprofit organizations
(18%), not reported (29%), both nonprofit and for-profit
organizations (14%), or for-profit organizations (39%).
JAMA 2003;290:921-928
Association of Funding and Conclusions in Randomized
Drug Trials: A Reflection of Treatment Effect of Adverse
Events?
JAMA 2003;290:921-928
Association of Funding and Conclusions in Randomized
Drug Trials: A Reflection of Treatment Effect of Adverse
Events?
JAMA 2003;290:921-928
Association between industry funding and
statistically significant pro-industry findings in
medical and surgical randomized trials.
• 332 randomized trials published between January 1999
and June 2001.
• 158 drug trials, 87 surgical trials and 87 trials of other
therapies.
• Industry funding declared in 122 trials (37%)
CMAJ 2004;170:477
Association between industry funding and
statistically significant pro-industry findings in
medical and surgical randomized trials.
CMAJ 2004;170:477
Source of funding and outcome of clinical
trials
• 107 clinical trials published in NEJM, Ann
Int Med, Am J Med, Arch Int Med in 1984.
• 76 (71%) favored new therapy.
• 31 (29%) favored traditional therapy.
J Gen Int Med 1986;1:155
Source of funding and outcome of clinical
trials
Industry Sponsored
Favored
New
Therapy
Favored
Traditional
Therapy
Yes
No
33
43
76
4
27
31
37
70
J Gen Int Med 1986;1:155
OR = 5.2 (95% CI, 1.7-15.5)
The uncertainty principle and industrysponsored research
• Reviewed all treatment studies of multiple
myeloma, 1996-98.
• 113 articles on 136 trials identified.
• Assessed quality on scale of 0-5 (<2 = poor).
• 27% of trials were commercially sponsored.
Lancet 2000;356:635
The uncertainty principle and industrysponsored research
Uncertainty principle (“equipoise”):
The patient should be enrolled in a randomized
controlled trial only if there is substantial
uncertainty about which of the trial treatments
would benefit a patient most.
– Overall, 56% of trials favored innovative vs 44%
favored standard treatment. (p=0.17)
Lancet 2000;356:635
The uncertainty principle and industrysponsored research
Industry Sponsored
Yes
No
Favored
innovative
treatment
27
46
73
Favored
standard
treatment
10
53
63
37
99
Lancet 2000;356:635
OR = 3.1 (95% CI, 1.4-7.0 )
The uncertainty principle and industrysponsored research
• Mean quality scores: industry 2.94, nonindustry 2.4.
• Proportion of trials comparing treatment to
placebo: 60% industry, 21% non-industry.
Lancet 2000;356:635
Evaluation of conflicts of interest in economic
analyses of new drugs used in oncology
• Evaluated economic analyses of 3 categories
of breakthrough drugs in oncology.
• 44 articles found in MEDLINE and
healthSTAR searches, 1988-98.
• 20/44 (45%) funded by pharmaceutical
companies.
JAMA 1999;282:1453
Evaluation of conflicts of interest in economic
analyses of new drugs used in oncology
Industry Sponsored
Yes
No
Favorable
Qualitative
Conclusions
19
15
34
Unfavorable
Qualitative
Conclusions
1
9
10
20
24
JAMA 1999;282:1453
OR = 11.4 (95% CI, 1.6-100.2)
Evaluation of conflicts of interest in economic
analyses of new drugs used in oncology
Industry Sponsored
Favorable
Unfavorable Qualitative
Conclusions
or neutral
quantitative
Unfavorable
results
Qualitative
Conclusions
JAMA 1999;282:1453
Yes
No
6
3
9
14
21
35
20
24
OR = 3.0 (95% CI, 0.69-12.8)
Evaluation of conflicts of interest in economic
analyses of new drugs used in oncology
“Although other sources of funds for pharmacoeconomic studies are needed, limiting the
publication of pharmaceutical company-sponsored
studies is probably not feasible or practical.
Pharmaceutical companies provide valuable
resources to many areas of academic medicine and
are a primary source of funding for pharmacoeconomic studies.”
JAMA 1999;282:1453
Evaluation of conflicts of interest in economic
analyses of new drugs used in oncology
Study funded by an unrestricted grant from Amgen,
Inc., which “had a contractual right to review and
comment on manuscripts and abstracts prior to
submission.”
JAMA 1999;282:1453
Association between competing interests and
authors' conclusions
• Randomized clinical trials published in the BMJ
from January 1997 to June 2001. 159 trials.
• Gathered data on authors' conclusions, competing
interests, methodological quality, sample size, type
of intervention, and type of control.
• Competing interest: “Anything that may influence
professional judgment.”
BMJ, 2002:325:249
Association between competing interests and
authors' conclusions
159 trials:
• 65 trials competing interests declared:
– 27 funding by for profit organizations.
– 19 funding by both for profit and non-profits.
– 19 “Other.”
BMJ, 2002:325:249
Most trials favored experimental intervention (higher score )
BMJ, 2002:325:249
BMJ, 2002:325:249
Reported Outcomes in Major Cardiovascular
Clinical Trials Funded by For-Profit and Notfor-Profit Organizations: 2000-2005
• 324 cardiovascular trials published between
January 1, 2000, and July 30, 2005, in JAMA, The
Lancet, and the NEJM.
• 137 trials funded solely by for-profits.
• 104 trials funded soley by not-for-profits.
• 62 trials jointly funded
• 21 no funding source cited
JAMA. 2006;295:2270-2274
Reported Outcomes in Major Cardiovascular
Clinical Trials Funded by For-Profit and Notfor-Profit Organizations: 2000-2005
• 49% of trials funded solely by not-for-profit favored
newer treatments over standard of care.
• 67.2% of trials funded solely by for-profit
organizations favored newer treatments over
standard of care.
• 56.5% of jointly funded trials favored newer
treatments.
JAMA. 2006;295:2270-2274
Reported Outcomes in Major Cardiovascular
Clinical Trials Funded by For-Profit and Notfor-Profit Organizations: 2000-2005
For drug trials (n=205):
• For-profit: 65.5% favored new treatment.
• Not-for-profit: 39.5% favored new treatment.
• Jointly funded: 54.4% favored new treatment.
JAMA. 2006;295:2270-2274
Reported Outcomes in Major Cardiovascular
Clinical Trials Funded by For-Profit and Notfor-Profit Organizations: 2000-2005
For device trials (n=39):
• For-profit: 82.4% favored new treatment.
• Not-for-profit: 50% favored new treatment.
• Jointly funded: 69.2% favored new treatment.
JAMA. 2006;295:2270-2274
Industry funding and design of clinical trials
A study of manufacturer-supported trials
of nonsteroidal anti-inflammatory drugs in
the treatment of arthritis
• All RCTs of NSAIDs in treatment of arthritis
indexed in MEDLINE between 9/87 and 5/90.
• 61 articles representing 69 trials met
inclusion criteria.
• 52 articles representing 56 trials associated
with pharmaceutical manufacturer (81% of
trials) .
Arch Int Med 1994;154:157
A study of manufacturer-supported trials
of nonsteroidal anti-inflammatory drugs in
the treatment of arthritis
• In 27 trials (48%), the dose of manufacturerassociated drug was proportionally greater
than the comparison drug.
• In all 16 trials where one drug was reported
superior (28% of trials), the drug was the
manufacturer-associated drug.
Arch Int Med 1994;154:157
Problems in the design and reporting of trials of
antifungal agents encountered during meta-analysis
• 15 eligible trials.
• 10 trials industry-sponsored, comprising 92%
of patients.
• 79% of control patients received oral
amphotericin B.
• In 3 trials (comprising 43% of patients)
amphotericin results were combined with
nystatin results.
JAMA 1999;282:1752
Journal supplements and symposia
The publication of sponsored symposiums
in medical journals
• Selected articles from 11 journals that had
published >10 symposia between 1980-1989.
• 625 symposia included.
• “Gold standard” 0 of 3: no misleading title,
no brand name, same peer review as parent
journal.
NEJM 1992;327:1135
The publication of sponsored symposiums
in medical journals
• 34/262 (13%) of articles with single drug
company sponsor met “gold standard” as
opposed to 66 of 89 (74%) of those with
non-industry sponsors.
• Sponsorship by single company associated
with single drug topics, misleading titles,
and use of brand names.
NEJM 1992;327:1135
The quality of drug studies published in
symposium proceedings
• Randomly selected 127 clinical drug studies
from symposia included in prior study.
• Quality of articles similar to parent journal.
• Articles with drug company support more
likely to be favorable to drug of interest
than those without support.
Ann Int Med 1996;124:485
The quality of drug studies published in
symposium proceedings
Industry Sponsored
Favorable
Unfavorable
Yes
No
39
89
128
1
23
24
40
112
Ann Int Med 1996;124:485
OR = 10.1 (95% CI, 1.6- )
Evaluating the quality of articles published in
journal supplements compared with the quality of
those published in the parent journal
• All RCTs published in Am J Med, Am J Card, Am
Heart J, 1990-92.
• 242 eligible trials
• Assessment of quality based on scoring system
devised by Chalmers.
• Supplements received lower score in 12 of 14 items
used to assess quality (mean scores: supplements
33.6% journals 38.5% (p=.01).
JAMA 1994;272:108
Industry funding and the research agenda
Relation between agendas of the research
community and the research consumer
• Published and unpublished studies on
interventions for treatment of osteoarthritis
• Focus groups of “research consumers”’
(rheumatologists, GPs, and patients)
Lancet 2000;355:2037
% patients ranking top priority
Relation between agendas of the research
community and the research consumer
100
80
60
60
40
Patient priority
Literature
36
26
21
20
3
4
0
Surgical Education
Drug
treatment and advice treatment
Lancet 2000;355:2037
Experts, guidelines, and conflicts of interest
Conflict of interest in the debate over calciumchannel antagonists
• In context of heated debate over efficacy of CCA’s
• Identified 86 authors of 70 articles on CCA’s
published between 3/95-10/96.
• Survey instrument evaluated interactions with
pharmaceutical industry.
• 80% response.
• 63% of authors had relationship with at least one
pharmaceutical manufacturer.
NEJM 1998;338:101
100
96
100
88
80
67
60
53
60
37
40
43
37
Supportive authors
(n=24)
Neutral authors
(n=15)
Critical authors
(n=30)
20
NEJM 1998;338:101
An
y
Co
m
pe
t
i to
r
0
CC
A
% with financial relationship with
manufacturer
Conflict of interest in the debate over calciumchannel antagonists
P<.001 for trends
Conflict of interest in the debate over calciumchannel antagonists
“Physicians and researchers simply need to disclose
their financial relationships with pharmaceutical
manufacturers appropriately. Medical professionals
should be able to evaluate the merit of individual
articles in the light of the authors’ disclosure of
conflicts of interest.”
NEJM 1998;338:101
Relationships between authors of clinical practice
guidelines and the pharmaceutical industry
• Authors of CPGs endorsed by North American and European
societies on common adult diseases published between 1991-99.
• Identified through MEDLINE search, reference lists,
interviews with experts.
• 44 CPGs with 192 authors were included.
• Survey instrument evaluated interactions with pharmaceutical
industry.
• 100 (52%) authors participated.
JAMA 2002;287:612
Relationships between authors of clinical practice
guidelines and the pharmaceutical industry
100
87
% authors
80
64
53
60
38
40
20
6
JAMA 2002;287:612
/C
ye
e
Em
pl
o
Eq
ui
ty
on
su
lta
nt
fu
nd
in
g
el
Tr
av
H
on
or
ar
iu
m
Sp
ea
ki
ng
An
y
re
la
tio
ns
hi
p
0
Relationships between authors of clinical practice
guidelines and the pharmaceutical industry
70
Do relationships influence treatment
recommendations?
% authors
60
50
40
30
19
20
10
7
0
Personal Recommendations
JAMA 2002;287:612
Colleague Recommendations
Relationships between authors of clinical practice
guidelines and the pharmaceutical industry
# of guidelines
Declarations contained within guidelines regarding
authors' interactions (n=44)
50
40
30
20
10
0
42
No declaration
JAMA 2002;287:612
1
1
Declared no
sponsorship
Declared
industry
support
received
Conflict of Interest:
Is Disclosure Enough?
Conflict of interest: “Set of conditions in which
professional judgement concerning a primary
interest tends to be unduly influenced by a
secondary interest”
Thompson, NEJM 1993;329:573
Dealing with conflicts of interest
•
•
•
•
•
Prohibition
Divestiture
Abstention
Mediation
Disclosure
NEJM 1993;329:573
Financial Associations of Authors
“In a statement in such articles, we report all relevant financial relationships; if an
author has reported no relevant financial relationships, there is no statement. We
apply the same policy to Sounding Board articles, Case Records, and
Perspectives. Our purpose in publishing financial-disclosure statements is to
inform readers of the existence of financial relationships that, in our
judgment, are pertinent to the article, and to affirm that we had access to this
information during our deliberations.”
N Engl J Med 2002; 346:1901-1902
Comparison of Nefazodone, the Cognitive Behavioral-Analysis
System of Psychotherapy, and Their Combination for the
Treatment of Chronic Depression
Editor's note: Our policy requires authors of Original Articles to disclose all financial ties with
companies that make the products under study or competing products. In this case, the large number
of authors and their varied and extensive financial associations with relevant companies make a
detailed listing here impractical. Readers should know, however, that all but 1 (B.A.) of the 12 principal
authors have had financial associations with Bristol-Myers Squibb — which also sponsored the study
— and, in most cases, with many other companies producing psychoactive pharmaceutical agents. The
associations include consultancies, receipt of research grants and honorariums, and participation on
advisory boards. Of the 17 other authors, 2 are employees of Bristol-Myers Squibb, 5 (L.M.K., G.K.,
I.M., R.M., D.V.) have no relevant additional financial ties, and the others have a variety of associations
similar to those just mentioned. Details are included as part of the article on the Journal 's Web site
(www.nejm.org) and are also available (as document no. 05552) from the National Auxiliary
Publications Service, c/o Microfiche Publications, 248 Hempstead Tpk., West Hempstead, NY 11552.
Financial Interest and Its Disclosure in Scientific Publications
“We are persuaded by the views of Bernat and colleagues, leaders in the
American Academy of Neurology, who argue that the purpose of public
disclosure of conflicts of interest is not to remove the conflict but to publicize
it ‘so that all relevant observers become aware of it and can modify
their opinions on the credibility of statements of the conflicted person
accordingly,’ which mitigates but does not resolve the conflict.”
JAMA. 1998;280:225-226.
Conflict of interest in the debate over calciumchannel antagonists
“Physicians and researchers simply need to disclose their financial
relationships with pharmaceutical manufacturers appropriately. Medical
professionals should be able to evaluate the merit of individual articles in
the light of the authors’ disclosure of conflicts of interest.”
NEJM 1998;338:101
Why disclosure is so popular:
• Provides potentially useful information.
• Maintains status quo. Researchers/speakers
don’t need to give up their COIs.
• Diminishes responsibility for the outcome.
Why focus on financial conflicts?
•
•
•
•
Voluntary; optional.
Objective.
Fungible.
Easier to regulate.
The perverse effects of disclosure?
Estimator
Advisor
J Legal Studies. 2005; vol 34: pp. 1-25
Why not just look at results of studies?
(I.e., “let the facts speak for themselves”)
• Peer review may be inadequate.
• Doesn’t address publication bias.
• Doesn’t address “research agenda.”
The Professional Society-Industry Relationship
Professional Society-Industry Ties
•
•
•
•
•
Meetings
Journals
Practice guidelines
Fellowships
Educational materials
ACP’s Mission:
To enhance the quality and effectiveness of health
care by fostering excellence and professionalism in
the practice of medicine.
Goals
• To establish and promote the highest clinical
standards and ethical ideals.
• To be the foremost comprehensive education and
information resource for all internists.
ollege of Physicians
American College of Physicians
ysician-Industry Relations
Guidelines on Physician-Industry Relations
of individual gifts, hospitality, trips,
of all types from industry by an
cian is strongly discouraged.
The acceptance of individual gifts, hospitality, trips,
and subsidies of all types from industry by an
individual physician is strongly discouraged.
of even small gifts can affect clinical
eighten the perception (as well as the
lict of interest.
The acceptance of even small gifts can affect clinical
judgment and heighten the perception (as well as the
reality) of a conflict of interest.
professionalism require the physician
industry gift or service that might be
bias their judgment, regardless of
ctually materializes.
The dictates of professionalism require the physician
to decline any industry gift or service that might be
perceived to bias their judgment, regardless of
whether a bias actually materializes.
ns should not accept any promotional
s, whatever their value or utility, if they
to cloud professional judgment and
ient care.
Ideally, physicians should not accept any promotional
gifts or amenities, whatever their value or utility, if they
have the ability to cloud professional judgment and
compromise patient care.
dicine 2002;136:396-402.
Annals of Internal Medicine 2002;136:396-402.
Mission
The mission of the AAFP is to improve the health of
patients, families, and communities by serving the
needs of members with professionalism and
creativity.
Professional Society Dependence
Cons:
• May influence guidelines, publications, and
actions of the Society.
• May result in biased CME.
• May damage Society’s standing as role
model for its members and the profession.
• May erode public trust and confidence in
the medical profession.
Professional Society Dependence
Pros:
• Meetings are cheaper.
• Meetings are better (more stuff; magicians,
massages).
Industry funding and continuing medical education
The impact of drug company funding on
the content of continuing medical education
• Content analysis of 2 CME courses discussing 3
calcium channel blockers, sponsored by 2 different
drug companies.
• Tape recordings of courses were transcribed,
reviewed independently by 2 reviewers.
• Identified mentions of: generic drug names, brand
names, clinical effects, comparative statements.
Mobius 1986;6:66
The impact of drug company funding on
the content of continuing medical education
Generic drug mentions
% total drug mentions
70
59.6
60
47
50
40
30
Drug X
30.7
27.9
Drug Z
20.5
20
Drug Y
12.5
10
0
Course 1
Mobius 1986;6:66
Course 2
P < .05 between courses 1 and 2
for all drugs
The impact of drug company funding on
the content of continuing medical education
Positive
Clinical effects mentions
% total drug mentions
Negative
70
60
50
40
30
20
10
0
63.5
Equivocal
50.7
46.8
35.1
35.133.331.5
33.9
20.9
15.6
14.2
Company Drug
Non-Conpany
Drug
Course I
Mobius 1986;6:66
Company Drug
19.5
Non-Company
Drug
Course II
P < .05 between company and
non-company drugs
Changes in drug prescribing patterns related to
commercial company funding of continuing
medical education
• 3 CME courses; 2 on CCBs, 1 on beta-blockers.
• Single (but different) drug company sponsored
each course.
• Survey of attendees prior to and 6 months after
each course.
• “From your memory, please indicate how many
new patients you started on each of the following
drugs within the last month. . .”
J Cont Ed in Health Prof 1988;8:13
Changes in drug prescribing patterns
related to commercial company funding of
continuing medical education
Course 1 (sponsor nifedipine)
% of prescriptions
60
50
54
48
40
30
22
26
20
30
20
Before
After
10
0
Nifedipine
Diltiazem
J Cont Ed in Health Prof 1988;8:13
Verapamil
P < .05 for before-after
difference for each
Changes in drug prescribing patterns
related to commercial company funding of
continuing medical education
Course 2 (sponsor metoprolol)
% of prescriptions
35
30
30
27
After
25
25
18
20
15
Before
32
14
10
5
0
Metoprolol
Atenolol
J Cont Ed in Health Prof 1988;8:13
Propanolol
P < .05 for before-after
metoprolol and propanolol
Changes in drug prescribing patterns
related to commercial company funding of
continuing medical education
% change in prescribing rate
Course 3 (sponsor diltiazem)
Matched Responses
60
54
50
44
37 40
40
30
31
24
22
24
22
20
Increased
Decreased
Unchanged
10
0
Nifedipine
Diltiazem
J Cont Ed in Health Prof 1988;8:13
Verapamil
P < .05 for all comparisons
When drug manufacturers’ employees present
grand rounds, what do residents remember?
• Retrospective cohort design
• 75 housestaff surveyed 3 months after industrysponsored grand rounds on Lyme disease.
• 22 (29%) housestaff had attended presentation.
• Speaker introduced as “executive employee of a
pharmaceutical company.”
• Asked about drug of choice for various stages of
disease.
Acad Med 1996;71:86
When drug manufacturers’ employees present
grand rounds, what do residents remember?
• Residents who attended the lecture were more likely
to choose appropriate therapy for 2nd degree heart
block.
• None of attendees chose appropriate (oral) antibiotics
for rash or 1st degree heart block, compared with 11
(21%) of non-attendees.
• Attendees were more likely than non-attendees to
name the speaker’s drug as DOC for 1st or 2nd
degree heart block.
Acad Med 1996;71:86
Is This Speaker Conflicted?
Is This Speaker Conflicted?
• Keeps using brand name by mistake.
Is This Speaker Conflicted?
• Keeps using brand name by mistake.
• Refers to competitor drug as “rat poison.”
Is This Speaker Conflicted?
• Keeps using brand name by mistake.
• Refers to competitor drug as “rat poison.”
• Wearing Bidil® Neck Tie.
Is This Speaker Conflicted?
•
•
•
•
Keeps using brand name by mistake.
Refers to competitor drug as “rat poison.”
Wearing Bidil® Neck Tie.
Company logo on slide.
Atherosclerosis,
Dyslipidaemia and
Diabetes
Is This Speaker Conflicted?
•
•
•
•
Keeps using brand name by mistake.
Refers to competitor drug as “rat poison.”
Wearing Bidil® Neck Tie.
Company logo on slide.
Is This Speaker Conflicted?
•
•
•
•
•
Keeps using brand name by mistake.
Refers to competitor drug as “rat poison.”
Wearing Bidil® Neck Tie.
Company logo on slide.
Subliminal images.
First Proportion
majorof patients
cardiovascular event
(%)
Difference in BP reduction
3.2/1.6 mmHg
0
6
Lithell et al, J Hypertens 2003
12
18
24
30
36
42
48
54
60 Months
First Proportion
majorof patients
cardiovascular event
(%)
16
Difference in BP reduction
3.2/1.6 mmHg
14
12
10
8
6
4
2
0
0
6
Lithell et al, J Hypertens 2003
12
18
24
30
36
42
48
54
60 Months
First Proportion
majorof patients
cardiovascular event
(%)
16
Difference in BP reduction
3.2/1.6 mmHg
14
12
10
8
6
4
2
0
0
(n)
(n)
2477
2460
6
12
2454
2423
Lithell et al, J Hypertens 2003
18
24
2371
2333
30
36
2262
2239
42
48
1587
1542
54
60 Months
406
401
First Proportion
majorof patients
cardiovascular event
(%)
16
Difference in BP reduction
3.2/1.6 mmHg
14
12
10
8
6
4
Risk reduction=10.9%
p=0.19
2
0
0
(n)
(n)
2477
2460
6
12
2454
2423
Lithell et al, J Hypertens 2003
18
24
2371
2333
30
36
2262
2239
42
48
1587
1542
54
60 Months
406
401
First Proportion
majorof patients
cardiovascular event
(%)
16
Control
Difference in BP reduction
3.2/1.6 mmHg
14
Atacand®
12
10
8
6
4
Risk reduction=10.9%
p=0.19
2
0
0
®
Atacand (n)
Control (n)
2477
2460
6
12
2454
2423
Lithell et al, J Hypertens 2003
18
24
2371
2333
30
36
2262
2239
42
48
1587
1542
54
60 Months
406
401
First Proportion
majorof patients
cardiovascular event
(%)
16
Control
Difference in BP reduction
3.2/1.6 mmHg
14
Atacand®
12
10
8
6
4
Risk reduction=10.9%
p=0.19
2
0
0
®
Atacand (n)
Control (n)
2477
2460
6
12
2454
2423
Lithell et al, J Hypertens 2003
18
24
2371
2333
30
36
2262
2239
42
48
1587
1542
54
60 Months
406
401
Just say no
to drug reps