IOM Report on COI: Yes, We Really Mean It

You can tell that I'm not a truly dedicated blogger because I allowed the small matter of being out of town for a few days to delay my posting on the big news of this past week, which of course is the new conflict of interest report just out from the Institute of Medicine. While there are a number of examples of media coverage, the best way into the Report is probably the full text available on line--

http://www.iom.edu/CMS/3740/47464/65721.aspx

--where you have the option of going into the report itself to find the 20-page executive summary, or else sneaking a peek at a couple of 4-page briefs. Also, the New England Journal posted a "Perspective" on the report on its website, that has a 1-page summary of the major recommendations:

http://content.nejm.org/cgi/content/full/NEJMp0810200

Full disclosure: First, I have read the NEJM perspective, the briefings, and the executive summary, but not yet the full report. (Told you I wasn't dedicated.) As a member of IOM I have a high opinion of that organization's heft and prestige. But I was not a member of the committee that wrote the report, and was turned down when I volunteered to be a reviewer of the draft. A couple of folks whom I respect very highly as bioethicists were members of the committee.

So what can I say based on the above? First, the report is quite comprehensive in the different sorts of COI that it addresses--medical practice; research; all levels of medical education; clinical guidelines; and academic institutions. The IOM panel recommends passage of the federal Physician Payment Sunshine Act but with expanded reporting requirements compared to the present bill now before Congress. In general, the report will disappoint some true believers, but comes down pretty strongly on the side of reformers who argue that the more arm's-length the financial relationship between the industry and medicine, the better. In short, from the perspective of this blog, it is a reasonably hard-hitting and positive report. Inevitably, given the multiplicity of previous reports on these matters (Robert Steinbrook in NEJM counted 16 that were cited), it breaks little new ground in its specific recommendations. So mostly the importance of the IOM report is to add further weight to these previous calls for reform.

There is one specific area where an interesting fight might be looming. IOM calls for a major overhaul of continuing medical education--without being able to say what the new system ought to look like, it is quite sure that we need to replace the current system where the industry pays for roughly half of all CME costs, to an industry-money-free system within 2 years. The ACCME, by contrast, that actually runs CME, reportedly (again according to Steinbrook) has said just recently that it is quite pleased with its present rules for managing COI with industry and sees no need for any major overhaul. (Ironically, the position I took in HOOKED would tend to support the ACCME position, at least until more evidence is gathered that the relatively new, stricter ACCME guidelines are not working as intended.)

The IOM is also forthright on an issue that many previous reports (but not HOOKED) have sidestepped. They note that universities are eager to enact policies that beat up their individual faculty over COI, but much less willing to face the prospect of institutional COI. They call upon boards of trustees to develop institutional COI oversight mechanisms and also for NIH to develop nation-wide rules on institutional COI. This at least begins to suggest that institutional COI will be addressed on a level where some sort of meaningful action can take place.