Commercial interests, transparency, and independence: a call for submissions

Problematic relationships

Since the 2009 IOM report, transparency has improved, but key recommended steps towards independence—such as prohibiting free meals, excluding conflicted authors from guidelines, and ending industry influenced medical education—have not been taken. These practices are still widespread despite continuing evidence of distorting impacts on research and practice. A 2010 cross sectional review found that the views of “key opinion leaders” strongly correlate with their sponsor’s interests.2 A 2016 study of 279 000 physicians, using the new US Open Payments transparency initiative (https://www.cms.gov/openpayments/), found an association between receipt of just one promotional meal and higher prescriptions of the sponsors’ drugs.3 A 2017 Cochrane review has confirmed that sponsored clinical trials tend to find more favourable outcomes about sponsors’ products.4 In 2018 new evidence has identified ongoing sponsor involvement in design conduct and reporting of research, and a lack of transparency around such involvement.5

Other work shows how companies can control information about their products by selectively publishing or suppressing data and even by changing the standards used to evaluate research,6 as described in figure 1. Investigative journalism continues to expose cases where financial interests have contributed to patient harm, as occurred with diabetes drug rosiglitazone,7 with infant formula,8 and with vaginal mesh.9 These examples bear witness to inadequate regulation, aggressive marketing, and a research establishment and medical profession still firmly entangled with industry.

Fig 1

Industry strategies to influence evidence and discourse about evidence

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The past decade has seen a growing and related understanding of the threat to human health from overdiagnosis and too much medicine (https://www.bmj.com/too-much-medicine). Recent research confirms the extent to which this medical excess is driven by commercial influences, including on disease definitions.10 By failing to mitigate these influences we overmedicalise society by labelling healthy people as sick, causing unnecessary cost to health systems and harm to patients.

The BMJ’s response so far

The 2009 IOM report described transparency as a “critical but limited first step in the process of identifying and responding to conflicts of interest.” It suggested that if medical organisations did not act to reduce conflicts then pressure would likely mount for external regulation. Taking up this challenge, The BMJ has updated its policies around ties with commercial companies (box 1).

These changes show that The BMJ aims not only to describe the, problem but to be part of the solution. They have led to difficult conversations, harder work, increased costs, or loss of revenue. Other organisations will have considered or taken similar steps. We would like to hear about these discussions and reforms, and where possible, outcomes and impact. We also welcome your thoughts on what we should focus on next.

The BMJ has also worked with the Centre for Evidence Based Medicine at Oxford University and a global community of evidence based medicine supporters to frame a manifesto for better evidence in medicine.14 One of the manifesto’s nine commitments is to reduce conflicts of interest to facilitate better creation, translation, and use of evidence. Our jointly hosted conference, EBM Live, will include a themed day on conflicts of interest in July 2019.

We recognise that taking a strong stance on commercial interests is just one piece of a wider picture of other financial and also non-financial interests. There are many differing perspectives, including from those who question assumptions about the dangers of conflicts of interest.15 By focusing on commercial financial interests we do not aim to minimise or avoid this wider discussion.

Call for submissions

Today, The BMJ launches a call for submissions for a themed collection (box 2). New transparency initiatives such as US Open Payments provide invaluable data, and we welcome research drawing on these new sources. There are also new and important relationships to study: those with commercial entities beyond drug companies, and those between industry and patient and consumer advocacy groups, which are rightly increasingly influential in the creation and use of evidence.

We intend to launch initial material at the Preventing Overdiagnosis conference in Sydney on 5-7 December 2019 (www.preventingoverdiagnosis.net) and the full collection at EBM Live in July 2020 (ebmlive.org). We look forward to receiving your work.