Monday, December 15, 2008

A Few Small Steps Towards Better Disclosure of Conflicts of Interest

Various kinds of conflicts of interest affecting medical academics, practicing physicians, and diverse health care decision makers have frequently been topics of discussion on Health Care Renewal.

Recently, on several fronts there have been moves to increase disclosure of financial relationships among health care decision makers and various health care organizations. For example, two weeks ago, the Cleveland Clinic announced it would post some information about the financial relationships of its physicians on its web-site. According to Reed Abelson reporting for the New York Times,

The Cleveland Clinic plans to announce this week it has begun publicly reporting the business relationships that any of its 1,800 staff doctors and scientists have with drug and device makers.

In particular,

Under the effort led by Dr. [Guy M] Chisolm, [Chair of the Cleveland Clinic Innovation Management and Conflict of Interest Committee,] every scientist and doctor employed by the clinic must report any industry relationship to the clinic at least once a year. Members of the committee, which meets monthly, typically interview the doctors involved, often requiring documentation like letters to academic journals alerting editors to the industry relationships.

The clinic has been working for more than a year to set up the public listing on its Web site, where consulting payments of more than $5,000 a year, and all royalty and equity interests, will be disclosed.

'Disclosure is a minimum,' said Dr. Chisolm, who hopes to begin listing the actual dollar amounts involved in a doctor’s consulting arrangements next year. The current disclosure simply lists the companies for whom the consulting takes place. He said the group was planning to improve the clinic’s ability to audit the information it received from doctors, because the clinic must now rely on doctors’ self-reporting to find potential conflicts.

My first comment is that in general, more transparency is better than less. For an elite institution like the Cleveland Clinic to start some sort of systematic reporting of such financial relationships is a step in the right direction.

However, it is, at the moment, a very small step. The sort of disclosures now appearing are extremely telegraphic. For example, here is what is appears about Dr Delos Cosgrove, the CEO of the Clinic, and the Chair of its Board of Governors,

Royalty Payments. Dr. Cosgrove has the right to receive royalty payments for inventions or discoveries related to the companies shown below:

* Allegiance (Cardinal Health)
* AtriCure
* Edwards Lifesciences
* Kapp Surgical
* Terumo

It is interesting to contrast the terseness of this text with the amount of detail about Dr Cosgrove's financial relationships that previously caused controversy (for example, see our posts here and here.)

Review of this and other listings suggest that for the moment, the only information that will be provided will be the broad nature of the relationships (royalty payments, consulting, etc) and the names of the companies or organizations involved. Perhaps in the future, the financial scope of these relationships will be revealed.

But the ostensible goal of this effort, according to Dr Chisolm, is to aid patients' decision making:

Guy M. Chisolm III, the cell biologist who is chairman of the conflict-of-interest committee, says patients should know about such links so they can talk to their doctors or others at the clinic about any financial tie that raises questions.

'Patients are vulnerable,' Dr. Chisolm said.
But how could a patient evaluate the sorts of disclosures that the Clinic is now making? How, for example, would a patient of Dr Cosgrove determine whether a royalty paid to him by one of the listed companies could have any influence on the care that patient would receive? Such a judgment might require some knowledge about whether the company makes any product that could be relevant to the patient's care, and whether the royalty was paid to the doctor for any reason relevant to the patient's care. It might be hard to even begin to make such judgments without some very detailed information along these lines. (Even with that information, it might be hard to judge the importance and influence of the relationship. We have noted findings from cognitive psychology that suggest people have great trouble judging the importance of disclosures about conflicts of interest, and determining the influence of such conflicts on the judgements and behaviors of the people who have the conflicts.)

So although the disclosure to be provided by the Cleveland Clinic is an improvement over what was done before, and an improvement over what most academic medical centers and medical schools currently do, it is only a small improvement.

The Times also reported that
As Dr. Cosgrove sees it, potential conflicts of interest need to be managed, not automatically eliminated, because working with industry encourages innovation by the clinic and its doctors. He has even made 'innovation management' part of the committee’s official title: the Cleveland Clinic Innovation Management and Conflict of Interest Committee.
As I have said before, it is not unreasonable to assert that collaboration between academic medicine and industry could lead to innovation. However, it is not clear to me why such collaboration must always entail payments, often large, by industry directly to individual academics. If such payments occur, it is also not clear to me that tersely disclosing their occurrence will "manage" them sufficiently.

By the way, while this was going on, further details came out about the state of Massachusetts new regulations mandating disclosure of financial relationships among physicians and health care corporations in that state. As discussed by Dr Daniel Carlat on the Carlat Psychiatry Blog, and by Alison Bass on the Alison Bass Blog, it appears that the disclosure initially required by the regulations would also be incomplete. In Massachusetts, no disclosure of any payments related to research would be required. So, once again, a baby step towards full transparency is better than no step at all, but not very much better. Given the pervasive nature of conflicts of interest affecting physicians, medical academics, and health care decision makers, and the questions these raise about in whose interest health care decisions are made, there is a very long journey ahead.

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