Branden Pfefferkorn , MD May 8, 2009 MPH Spring Symposium

1. Comparing policies on health industry conflicts of interest at academic medical centers: peer pressure’s positive power BrandenPfefferkorn, MD May 8, 2009 MPH Spring Symposium

2. Acknowledgements • Committee 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 Director • AMSA leaders: Rebecca Sadun, Nitin Roper, Jack Rusley • Pat Remington, MD, MPH and Barb Duerst, RN, MS • Ellen Selkie, MD, Analisa Calderón, family and friends

3. Overview • Background • Introduction to the PharmFree Scorecard • Project Objectives • Scorecard Methodology • Results • Discussion • Conclusions

4. Background • Health 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

5. The 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

7. Project Objectives • Update the Scorecard for 2009 • Increase both external and internal awareness (communicate with press) • Begin to assess policy implementation, monitoring, and adherence • Transition leadership to 2010 director

8. Scorecard Methodology-Policy 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

9. Making the grade • Scores of best three sub-domains are averaged • A ≥ 85% B ≥ 70%C ≥ 60%D ≥ 40%F <  40% I = In Process

11. Results • 2008: 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

12. Press Coverage

13. Discussion: Inducing organizational isomorphism • DiMaggio & 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

14. Discussion: Limitations • Potentially 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)

15. Other Public Health Implications • Use of a scorecard model • University technology transfer & access to technologies • The 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?

16. Conclusions • 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

17. Thank you! Questions? Branden Pfefferkorn branden.pfefferkorn@gmail.com www.amsascorecard.org Monday, June 8: Scorecard 2009 release

18. Perspective A 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 Pediatrics 1961

20. Scorecard Timeline

22. 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