Financial Conflicts of Interest Concerning Among Clinical Pathway Vendors

PageIn the February issue of JAMA Oncology, a research letter was published regarding the financial conflicts of interest among oncology clinical pathway vendors. Bobby Daly, MD, MBA, and Peter B Bach, MD, MAPP, both with Memorial Sloan Kettering Cancer Center (New York, NY), as well as Ray D Page, DO, PhD, The Center for Cancer and Blood Disorders (Fort Worth, TX), collaborated to quantify the conflicts of interest for oncology clinical pathways committee members and those who contribute to development of such pathways.

Journal of Clinical Pathways spoke extensively with Drs Daly and Page regarding the ramifications of such conflicts of interest and the potential issues of full transparency on the part of committee members.

The research letter references that almost all physicians involved in clinical pathway development received non-research payments. Do you find this disconcerting? What are the potential ramifications of such conflicts of interest?

Dr Daly: I think the potential ramification of a conflict of interest is that without transparency there can be a lack of trust on the part of providers, patients, and other stakeholders who use these pathways in part of their delivery of care. So, understanding what the conflicts of interest are, and those who create these pathways, are things that can reassure patients and providers that the pathways are created in a way with a focus on the patient and providing that optimal care.

We really wanted to focus on non-research payments because a lot of the experts who are developing these pathways will be receiving research payments because they are helping to develop those next innovative medications that are advancing the field forward. We understood that a lot of them would receive research payments.

The non-research payments can include things like gifts, speaker fees, etc. We thought that was the area that we really wanted to focus on. In thinking through if it is disconcerting or not, one thing we have to better understand is what is the amount of payment that really can have an influence on people’s viewpoints. That is a topic still undergoing study, but it is something that should be considered when these vendors are creating their conflict of interest statements for these pathway committees.

Dr Page: Many physicians have different views on the ethics of receiving non-research payments and how that may conflict doctors in the whole world of medicine. I do not find physicians receiving non-research payments as disconcerting at all. Let us face it – we are all theoretically conflicted in every aspect of our lives based on our perceptions, our knowledge, and our experiences. For physicians that are at the top of their game, that are innovators and educators and researchers and thought leaders, they are going to be asked for their expertise and opinions. In almost all professions, including our lawmakers, our time, our effort, and our sharing of knowledge and expert opinion does have value and that can include financial payments from time to time. I actually find that a lack of transparency and non-disclosure of conflicts of interest as disconcerting.

So, as for the ramifications of this, conflicts of interest should be disclosed. Members of a panel should be representative in a way that conflicts will be counterbalanced. A majority of members on a panel should not share the same financial conflicts. If you have a diverse group, that should mitigate conflicts, whether they are financial or not, just by having increased transparency and accountability and fairness. 

A rebuttal to the idea of releasing the identities of the individuals involved in the clinical pathway process is the potential for these individuals to be lobbied by numerous entities. Do you believe this is a legitimate argument against full transparency? What would you suggest as a potential compromise?

Dr Daly: Absolutely. When the bill that we mention in our article came for debate in California, a lot of the rebuttal against that bill was that in providing the names of those who are creating these pathways, they could then be lobbied by pharmaceutical companies who would try to influence the development of the pathways. I think that highlights some of the complexity of the issues of pathway development. It also shows how important these pathways are because if there is real concern, that is just another indication that these pathways are having a big effect on clinical practice.

I do think there is a precedent that people who are involved in guideline development are transparent, so that you can go on NCCN and see who are those providers, physicians, others who are responsible for creating those guidelines. I do think we have a precedent of providers and patients knowing who is taking part in development of these guidelines.

I think one potential first step, or potential compromise would be to provide at least a de-identified list of who is creating these pathways and what their conflicts of interest are and their qualifications. But I think full transparency is really what we should hope for the pathway panel. 

Dr Page: I think transparency and accountability supersedes the individual risk of having perverse outside influences. Certainly, there is a lot of outside entities that have a desire to influence opinions and votes, and the physician can manage the degree of those interactions with those interested parties. I think a balanced and diverse committee should be able to overcome the risk of an individual influence from lobbying from outside groups. If adverse conflicts occur, if a pattern results from a lack of accountability, then that member should be removed from the panel and there should be processes in place for those kinds of issues when they arise.   

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