Survey Exposes Conflicted Attitudes Toward Industry Funding of CME

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Medical professionals largely agree that commercial support introduces bias into continuing medical education (CME). Yet many are unwilling to pay higher registration fees to eliminate industry’s influence from such courses, according to results of a survey published in the May 9, 2011, issue of Archives of Internal Medicine.

Researchers led by Jeffrey A. Tabas, MD, of the University of California San Francisco School of Medicine (San Francisco, CA), sought to assess attitudes among CME participants about industry funding and the risk of undue influence, their willingness to shoulder some of the expense of CME activities, and their understanding of the actual costs involved. The 22-item survey was offered to 1,347 attendees at 5 accredited CME courses delivered by the International AIDS Society-USA in 2009 in New York, NY; Atlanta, GA; Chicago, IL; San Francisco, CA; and Washington, DC.

Majority Perceive Bias, But Few Would Take Action

In all, 770 attendees (57%) turned in completed surveys. Fifty-five percent were physicians; 35% were registered nurses, nurse practitioners, or physician assistants; and 10% had a PhD or other academic degree. A little more than half (56%) had been in practice for 10 to 30 years, while 13% had been in practice for more than 30 years. Of 389 attendees who responded to a question about external funding, few had received commercial funding for research (3%) or for any educational event or presentation (12%), and few had served as industry consultants (9%). However, the majority (76%) had attended commercially sponsored dinner lectures.

The idea that commercial support introduces bias was held by 88% of those surveyed, and the amount of bias was linked to the degree of commercial support.

Looking specifically at physician responses, 86% thought that CME activities supported by a single company would have moderate or large potential for bias, while 70% had the same impression when 2 or more companies provided support. Most physicians perceived a moderate or large potential for bias from faculty members who served on commercial speakers’ bureaus (73%) or received research support from industry (68%) but not from those who received no industry funding (5%).

Despite this perception of undue influence, only a small proportion of physicians (17%) strongly or somewhat agreed that pharmaceutical and medical device company support should be eliminated from accredited CME events. In fact, 56% found this support to be essential. Fewer than half (46%) agreed that raising registration fees could help offset industry support. Those who perceived more likelihood of bias were more likely to endorse raising fees or eliminating commercial funding. While most (56%) would be willing to use online rather than printed syllabi to save money, a similar proportion reported they would accept a less desirable venue or give up free food and snacks (50% for both questions). Smaller segments were willing to have fewer topics and speakers (11%) or accredited CME hours (15%).

Participants also were asked to estimate the costs of lunch per person and a cup of coffee at their mid-priced, chain hotel venues. Actual prices ranged widely. Lunch cost anywhere from $49 in Atlanta to $117 in New York, while coffee ranged from $4.90 in Washington, DC, to $8.47 in New York. Approximately 85% of all respondents underestimated lunch prices, while 88% underestimated coffee prices. The majority (75%) simultaneously overestimated the percentage of expenses that were covered by attendee registration fees.

Difficult Choices

How exactly to provide quality CME with alternate funding or at reduced cost remains a dilemma, Dr. Tabas and colleagues note. “One suggestion is to reduce costs by holding meetings and events at less expensive facilities and locations, or reducing speaker honoraria,” they suggest. “Barring a substantial reduction in the cost of delivering CME, however, a rapid reduction or elimination of funding might be unacceptably disruptive, and some have postulated that such a change will result in the disappearance of live CME as we know it and the development of other forms of CME.”

Although some academic institutions have already successfully implemented policies that prohibit commercial support of CME, it is crucial to understand the perceptions of health care professionals when considering sweeping changes, the investigators stress. They refer to an Institute of Medicine report that estimated physicians spent approximately $1,400 for CME in 2007; the cost of attendance would increase to $3,500 per year if commercial funding were eliminated.

In an editorial accompanying the paper, Todd Dorman, MD, of the Johns Hopkins University School of Medicine (Baltimore, MD), and Ivan L. Silver, MD, MEd, of the University of Toronto (Toronto, Canada), emphasize that according to the survey, “attendees neither fully understood the real costs associated with conducting an accredited activity nor were willing to accept higher registration fees. The attendees were willing to see some amenities trimmed, including preprinted syllabi, choice of venue, and refreshments. These last 2 issues are intimately linked and will likely have an impact on the field quickly because expense control is almost easier and faster than changes in revenue.

“Physicians should indeed understand more clearly the true costs of ongoing education, and a more modest approach, when appropriate, is unlikely to negatively influence educational outcomes,” the editorialists note.

However, CME funding is likely to become ever more complicated, as the “field is moving toward performance improvement with assessments of patient outcomes, simulation-based CME, and enhanced hands-on workshops designed to actively improve performance. These are becoming the primary preferred modes of CME because they are outcomes oriented. However, these more individualized and small group activities will likely drive costs up further,” Drs. Dorman and Silver comment, adding that the need for alternative funding is already becoming apparent as industry has reduced its contribution to CME by nearly $500 million over the past few years.

CME Scene Evolving

In a telephone interview with TCTMD, Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), agreed that commercial support of CME activities is a challenging issue.

“To completely eliminate such support, which would then presumably reduce the level of bias, would fundamentally change the way that medical education occurs in the United States,” he explained. “And at a time of constrained costs, particularly on the governmental side, it’s difficult to imagine a scenario where these types of learning experiences can happen [without industry funding].” Particularly in more specialized fields, he added, it also can be hard to find faculty members who are both knowledgeable and lack industry funding, because companies typically seek out physicians with expertise to serve as consultants.

One good thing, Dr. Kirtane noted, is that oversight of CME has evolved through standards set up by the Accreditation Council for Continuing Medical Education and increasing awareness on the part of industry supporters. “The physicians don’t want bias, and the companies don’t want to appear biased, nor do the CME [providers]. That’s a good environment to hope that the bias will be reduced,” he said.

Dr. Kirtane pointed out that the survey’s format may have increased the proportion of respondents who reported potential for bias.

“These were hypothetical scenarios asking, ‘If this were to occur, would this introduce bias?’ That a different question from, ‘Was the event you’re at now conducted free of bias?’ And what’s interesting is that if you look at surveys from major medical meetings that offer CME and are supported by industry, some of these meetings actually have great ratings in terms of their perception of being free of bias,” he commented.

Even though asking the questions this way may have changed survey findings, “I don’t want to diminish the issues that the authors raise, because they are important,” Dr. Kirtane stressed. “I will also say, though, that anyone with ‘street smarts’ will tell you that there’s pretty much nothing in the world that’s free of bias. If you eliminate industry bias, you could inadvertently promote anti-industry biases and agendas. I think that’s an important point that often gets missed.”

 

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Sources:
1. Tabas JA, Boscardin C, Jacobsen DM, et al. Clinical attitudes about commercial support of continuing medical education: Results of a detailed survey. Arch Intern Med. 2011;171:840-846.

2. Dorman T, Silver IL. Continuing medical education: Is perception reality? Arch Intern Med. 2011;171:847-848.

 

 

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