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Health service researchers – are we blind to our own conflicts of interest?


Ritika Goel’s recent commentary on Healthy Debate about the pharmaceutical industry’s influence on physicians got me thinking about other kinds of conflict of interest within the health care system, particularly related to health services researchers.

There is a great need for researchers to be independent when conducting their work, and to be able to speak freely about research-related issues.

I think those of us who are health services researchers tend to under-appreciate the potential impact that government funding has upon our willingness to speak entirely freely in public about health policy issues.

Let’s compare the criticisms of those researchers who receive funding from industry, with those health services researchers whose salaries are paid by government and sometimes advise government.

Legitimate criticisms of the pharmaceutical industry are that they do not publicly release all relevant information about their products, and that their marketing materials are often not balanced.

However, very similar criticisms can be levelled at government and other major actors in the health care system. The Centre for Law and Democracy recently ranked Canada 55th of 99 countries in regard to “right-to-know” legislation.  Kevin Donovan of the Toronto Star has described the difficulty he has had accessing important information that the public has a right to know from numerous public or quasi-public actors within the health care system including ministries of health, hospitals and regulatory colleges.

The pharmaceutical industry also often requires their academic and clinical consultants to sign confidentiality agreements (thus inhibiting them from speaking freely about the company’s products), and they usually pay these consultants well (which may affect their ability to be unbiased).

Again, it’s not that different with government, although they tend not to pay as much as pharma. A recent report from University of Victoria researchers has documented the restrictions Canadian governments place on their scientists’ ability to speak freely about their work. A recent article in Macleans documented worrisome instances of the muzzling of federal scientists working in ministries relevant to the environment and climate change – I would not be surprised if this also extends to scientists working in federal health-related ministries.  These examples of censorship and message control seem particularly egregious, because the funds to support this research come from tax-payers.

Most of us who have functioned as advisors to government have signed confidentiality agreements, which are similar to those signed by consultants to industry.

Many health service researchers who are not directly employed by government still receive some or all of their salaries from government, and they often work in research institutes substantially funded by government. It seems to me that this can put us in a similar potential conflict of interest as industry funding places those who consult for industry. However, many of my colleagues do not appear to agree with me.

For example, Evidencenetwork.ca, a web site that provides journalists and others with access to “non-partisan health policy experts and evidence” removed me from their list of experts because I received about $15,000 per year for work I did for three pharmaceutical companies (being a member of Data Monitoring Committees and providing advice about the design of clinical trials).  However, my guess is that they would not have seen any significant conflict of interest with my previous role as CEO of the Institute for Clinical Evaluative Sciences (a health services research institute that receives millions of dollars of funding from the government of Ontario), even though the personal payment I received from public provincial funds was much greater than what I received from pharma, and when I was CEO I had a clear interest in not criticising the Ontario government publicly about their health policies, because government support was essential for the survival of ICES. (Click here for evidencenetwork.ca’s COI policy.)

To be clear, the government never pressured me to change the design of any studies or to bury the results of any study (but neither has pharma tried to muzzle me). However, I think I would be naïve to think that being the CEO of ICES had absolutely no impact on my willingness to speak freely about all politically charged health policy issues.  If I was approached by the press for comment, would I be willing to publicly strongly criticize a prominent new government health system strategy that I thought was misguided in the middle of a contract negotiation with the government? I suspect I would find a way of slightly tempering my views (without being dishonest) or being unavailable for comment.

At this point, it is important to make the distinction between funding for research that goes directly from government to researchers or the research institutes they work in, and government funding that is given to “peer-reviewed” granting agencies such as the Canadian Institutes for Health Research and Alberta Innovates – Health Solutions. Because the government has no say in the selection of the scientists or projects that receive peer-reviewed funding, scientists are very likely to feel totally free to speak their mind about their research.

It might be worthwhile articulating different degrees of conflict of interest. One scheme might go as follows, in order of increasing conflict of interest: 1) receipt of only operating funds to conduct the research from the payor,  2)  receipt of personal salary or consulting fees,  3) receipt of funds for a research group or institute, so many individuals are dependent upon those funds for all or part of their salary and/or projects, and 4) potential to derive entrepreneurial profits in partnership with the payor. An important point here is that, except for the fourth conflict, the others pertain to both industry and the public sector.

So, what to do? Many of the people I respect the most within health care, and who have the most to offer, are highly connected – with government, health care institutions, organized medicine, the pharmaceutical and device industry, academia, patient advocacy organizations, and others. Interactions with each of these groups influences the way these people think. Does that make them more biased, or does it make them more knowledgeable? I suspect both.

I have a lot of time for thoughtful, well connected people with multiple biases, provided they recognize them, and publicly identify them. My issue right now is that some health services researchers seem blind to the potential conflict of interest associated with government funding.

Andreas Laupacis is a general internist, the Executive Director of the Li Ka Shing Knowledge Institute of St. Michael’s Hospital and the Editor-in-Chief of Healthy Debate. Follow Andreas on Twitter @AndreasLaupacis

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10 comments

  1. Gerry Goldlist

    Thanks for that balanced article showing possible biases for public and private researchers. The most important thing is the quality of the study, the appropriate use of stats and the honesty of the researchers.

  2. David Naylor

    It’s about time someone belled this cat. Thank you, Andreas. More generally, it seems to me that health policy analysis, like clinical practice, remains far from an exact science. The conclusions inevitably reflect not just evidence, but values and circumstances. Can’t really be otherwise, but I do wish the values and contextual assumptions that colour many interpretations of policy-relevant evidence were acknowledged more often in more places.

    Best wishes,

    David Naylor

    • Jeremy Petch

      I agree, David. I’m amazed how many otherwise brilliant researchers seem entirely unaware of the value assumptions that underlie their work and influence their interpretation of the data. It speaks to the siloing of research, as there are entire research enterprises (philosophy and ethics) devoted to understanding these value assumptions and subjecting them to rigorous analysis. As you say, values and context are essential to the research enterprise, but it’s disappointing that so few researchers analyse these with the same thoughtfulness they bring to their statistics, data collection, etc.

      Best,

      Jeremy Petch

  3. Michael Schull

    Thanks Andreas for addressing an important question. Any thoughtful researcher, whether in health services, basic sciences, or clinical epidemiology should acknowledge that biases of all sorts may influence their research. As Gerry points out, the first step to reducing bias is to ensure sound methodology and appropriate conclusions based on your results. The second, often harder step is to avoid going beyond those conclusions in subsequent comments. Given the complexities involved in policy implementation, the varied approaches to evaluation, and differing perspectives of observers, it is rare to have a clear-cut yes or no to the question “did the policy work?” Furthermore, as researchers, even ones who advise government, we often have very little experience with policy development and implementation, which seems to be an art of the possible. For all these reasons, being circumspect in conclusions and statements seems appropriate, regardless of who is funding who.

  4. Don Taylor

    Well said, Andreas. I wonder also why healthcare professionals seem to ignore the conflict of interest created by having their costs of attending conferences, etc. directly covered, in whole or in part, by pharma and other private sector suppliers to the healthcare sector.

  5. Judy Glennie

    Dear Andreas – many thanks for raising this issue. Having worked on all sides of the fence, I’ve seen bias (real or perceived) come into play regardless of background. To paraphrase as a very wise Dr. Jean Gray at a CIHR-DSEN meeting several years ago, when you’ve sat at a formulary committee for 20 years you can’t tell me that you don’t have any biases. The issue is getting it all out on the table and being realistic about the impact (again, real or perceived) of the biases. To put things into perspective, a single pharma person (or government person or patient, for that matter) at the table doesn’t magically make the majority of other smart people in the room think in a different way. But they could raise relevant scientific issues that you never thought about – and if you are really interested in “the truth” (whatever that might be), wouldn’t you at least want to listen, consider and then make up your own mind?

    Thanks again for your wise words, Andreas!

    Best regards,

    Judy Glennie

  6. Solly Benatar

    Conflict of interest issues go even further. Foreign aid from the USA has long been openly linked to US interests. Now Canadian foreign aid will be linked more directly to Canada’s economic self-interest.

    http://www.thestar.com/news/canada/federalbudget/2013/03/21/federal_budget_2013_tories_fold_cida_into_foreign_affairs_department.html

    Attempts to improve the health of poor and vulnerable people globally as part of such a strategy could compromise health researchers using such resources.

    Much ink has been spilt on ethics in research and ethics for research but the ethics of research (how and by whom the agenda is set) has been largely ignored.

  7. Tom Closson

    I think the primary goal of researchers should be to provide evidence using unbiased methods. Nevertheless, given that we would like their evidence to have an impact, the manner in which researchers communicate evidence needs to consider how to encourage government to establish policies that will contribute to achieving a high performing healthcare system. Researchers need to understand and take into account how government works when they communicate or their research may be lost to a shelf collecting dust.

  8. David Henry

    Andreas – In drawing a parallel between conflicts of interest created by industry and government funding I feel that you conflate two activities – conducting/reporting research and commenting on government policy.

    Like you, I’d like to draw in part on my experience at ICES. In my role as CEO I must do what I can to ensure the accuracy and impact of our research findings. I would resist strongly any attempt by government (or anyone else) to change any result or change the wording of a report. In my 6 years at ICES, and many hundreds of reports, this has not happened. In the past when I worked with industry support, it did. When we surveyed over 800 clinician researchers in Australia 8.6% reported actions or requests by pharmaceutical companies that could be considered serious breaches of research integrity.

    Most ICES scientists are cross-appointed with universities and other institutions and some comment regularly and freely on policy matters. But should I as CEO do this? To me the answer has as much to do with the constraints placed by role and position as it does the funding source. We are a non-profit corporation that carries out research. We are not a policy institute. I think my Board would take a dim view if I was out regularly commenting (positively or negatively) on government policy. That would be a conflict of commitment rather than interest. Would I speak out if I felt that a government policy was harming people? Of course I would.

    We are all influenced to a degree by multiple factors and that includes funding sources. We all experience conflicts of commitment and interest. But I disagree that the conflicts created by government and industry funding are qualitatively similar.

  9. Joel Lexchin

    Andreas equates biases associated with government funding to those associated with industry funding but in doing so I believe that he conflates a number of issues that should remain separate. First, let me be clear. I think that both industry and government suppress (or try to suppress) information that they think is unfavourable to them. In the case of industry it’s information that may affect product sales and in the case of government it’s information that runs contrary to the political philosophy of the government or that may affect the political popularity of the government. However there is also significant evidence that industry funding biases the information itself. A Cochrane review in December 2012 found that industry funding of drug clinical trials compared to funding from other sources produced positive results (odds ratio 2.15 (95% CI: 1.70 to 2.72) and positive conclusions (odds ratio 2.67 (95%CI 2.02 to 3.53). (Full disclosure, I’m one of the authors of the Cochrane review.) I’m not aware of any literature that shows that government funding produces the same positive biases.

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