Comparing policies on health Comparing policies on health industry conflicts of interest at industry conflicts of interest at academic medical centers: academic medical centers: peer pressure’s positive peer pressure’s positive powerpower

Branden Pfefferkorn, MDMay 8, 2009MPH Spring Symposium

AcknowledgementsAcknowledgementsCommittee members:

◦ Sarah Davis, JD, MPA◦ Lee Vermeulen, MS, RPh◦ Mark Wegner, MD, MPH

The Pew Prescription Project/Pew Charitable Trusts◦ Gabrielle Cosel◦ Allan Coukell, BSc.◦ Two intern reviewers

Center for Patient Partnerships◦ Meg Gaines, JD, LLM and Aphra Mednick, MSW, LCSW

Gabriel Silverman, 2008 Scorecard DirectorAMSA leaders: Rebecca Sadun, Nitin Roper, Jack

RusleyPat Remington, MD, MPH and Barb Duerst, RN, MSEllen Selkie, MD, Analisa Calderón, family and

friends

OverviewOverviewBackgroundIntroduction to the PharmFree

ScorecardProject ObjectivesScorecard MethodologyResultsDiscussionConclusions

BackgroundBackgroundHealth industry marketing influences

medical education and, by extension, prescribing behaviors

Industry relationships in academic medical centers are common

Bias is not just a result of individual behaviors or attitudes

Perceptions of industry influence may affect patient adherence to treatment recommendations

The PharmFree ScorecardThe PharmFree Scorecard

The American Medical Student Association ranked all US medical schools on their conflict of interest policies

The 2008 version provided a rigorous methodology

The scorecard will be updated annually to allow schools to revise the evaluation

When given permission, the school’s policy is uploaded to the scorecard website

Resources are made available to schools for developing policy

Project ObjectivesProject ObjectivesUpdate the Scorecard for 2009Increase both external and

internal awareness (communicate with press)

Begin to assess policy implementation, monitoring, and adherence

Transition leadership to 2010 director

Scorecard Methodology-Scorecard Methodology-Policy AssessmentPolicy Assessment

Two blinded reviewers assess policies using the scoring instrument

Evaluated domains:◦ 1. Individual gifts◦ 2. Pharmaceutical Samples◦ 3. Purchasing & Formularies◦ 4. Industry Sales Representatives◦ 5. Education◦ 6. Enforcement (not scored)

0-3 score in each domain

Making the gradeMaking the gradeScores of best three sub-domains

are averagedA ≥ 85%

B ≥ 70%C ≥ 60%D ≥ 40%F <  40% I = In Process

ResultsResults2008: 115 of 151 schools

participated (76%)13% had A’s or B’s, around 25%

were “in process”Due to the Scorecard, medical

schools receive feedback from:◦ Popular press articles◦ Applicants◦ Administrators◦ Current students

Press CoveragePress Coverage

Discussion: Inducing Discussion: Inducing organizational organizational isomorphismisomorphismDiMaggio & Powell 1983

◦ Isomorphism is “the resemblance of a focal organization to other organizations in its environment”

◦ Organizational legitimacy is conferred by regulatory endorsement and public endorsement

◦ Explosion of popular press, numerous professional organizations moving toward limiting influence (AAMC, APA, IOM), and Congress and the NIH have been involved

Discussion: LimitationsPotentially valuable collaborative

relationships between industry and academic medical centers are lost

The costs and harms of implementing policies should be evaluated

The effectiveness of policies in reducing identified conflicts of interest is also an important avenue for further research (cautionary tale provided by disclosure policies)

Other Public Health Other Public Health ImplicationsImplications

Use of a scorecard model ◦ University technology transfer & access to

technologiesThe trouble with isomorphism

◦ Early adopters lose legitimacy if their position is not broadly adopted (e.g. Madison smoking ban)

Other uses of organizational isomorphism:◦ Green businesses◦ Reducing health disparities?

ConclusionsConclusions

The PharmFree Scorecard establishes a standard for effective conflict of interest policies at academic medical centers

Academic medical centers face multiple pressures to implement more stringent policies

Inducing institutional change has other public health applications

Thank you!Questions?Branden Pfefferkorn

branden.pfefferkorn@gmail.com

www.amsascorecard.orgMonday, June 8: Scorecard 2009 release

PerspectiveA vicious cycle is created by a mad scramble for a share of the market: the doctor is made to feel he needs more “education” because of the prolific outpouring of strange brands but not really new drugs, produced for profit rather than to fill an essential purpose; and then the promoter offers to rescue him from confusion by a corresponding brand of “education.”

Charles D. May, editor of Pediatrics1961

Scorecard TimelineScorecard Timeline

Scorecard recognition“Particular incentives can have both positive

and negative aspects. For example, when it rated medical schools on their conflict of interest policies, the American Medical Student Association used the “sunshine” of publicity in ways that were positive for schools that it viewed as having good policies and possibly embarrassing for the schools that it viewed as having deficient policies.”

Institute of Medicine Report, 4/28/2009