We have focused much less lately on the Physician Payment Sunshine Act, in part because the legislation had become bundled into the larger Senate health reform bill and hence awaited the fate of that legislation. So it was easy to forget last night that Sunshine was along for the ride when the House passed the Senate version of health reform. Thanks to our friends at the Pew Prescription Project for this announcement:
PEW STATEMENT ON THE PHYSICIAN PAYMENTS SUNSHINE ACT
WASHINGTON – Allan Coukell, director of the Pew Prescription Project, issued the following statement today, commending Congress for including provisions from the Physician Payments Sunshine Act in health care reform legislation. The provisions would require drug and device companies to publicly report the gifts and payments they make to doctors.
“Patients deserve to know if their doctors are receiving money from drug companies. Congress has added much needed transparency to the financial relationships between the pharmaceutical industry and physicians. The reporting requirements in the health care legislation will better protect patients and will help restore trust in our health care system.
“A study in the New England Journal of Medicine reported that more than 90 percent of physicians have some financial relationship with the pharmaceutical industry. We also know that companies spend at least $25 billion each year marketing to doctors. While many relationships between academic medicine and industry are necessary and beneficial, they create potential conflicts of interest that can influence prescribing and drive up costs.
“This new legislation will enhance the safety of consumers by increasing transparency while in no way restricting business or limiting innovation.”
Monday, March 22, 2010
BMJ Study: COI Associated with Substantial Bias on Rosiglitazone Dangers
In HOOKED, I mentioned a classic study by Stelfox et al. (NEJM 338:101-6, 1998) showing that financial conflicts of interest were strongly associated with the position authors took on the potential risks of calcium channel blocking drugs. In those olden days, Stelfox et al. found that only 3% of the articles they surveyed explicitly disclosed authors' COI.
To see what progress we have made since then, Dr. Amy T. Wang and colleagues in internal medicine at the Mayo Clinic decided to do a review of comments made after the publication of two major studies on rosiglitazone, one claiming that there was increased risk of heart attack, the other minimizing such risk. Their results have been published on line in BMJ (subscription required). (Hat tip to Dr. Roy Poses and the Health Care Renewal blog for mentioning this paper.)
Using careful statistical methods the authors first retrieved a set of papers (including editorials and letters to the editor as well as research studies) that cited the two initial studies. They did extensive searches to identify whether the authors had any COI with the makers of rosiglitazone, the makers of its major competititor drug, pioglitazone, or of any other oral diabetes drug. They then blindly classified the contents of each paper as positive/negative as to the heart attack risks of rosiglitazone and/or as recommending/not recommending its continued use.
Bottom line: even in this supposedly more enlightened age they found explicit COI statements in only 53% of the 202 papers they surveyed. The found authors with COI more than 3 times as likely to be positive about rosiglitazone or to recommend its use.
The results also argue against a rationalization sometimes heard by defenders of taking industry largesse--that if you take bribes from enough different companies, they all cancel out in the end. COI was associated with a greater likelihood of minimizing heart risk and recommending rosiglitazone whether the company from which the author had received payment manufactured rosiglitazone, pioglitazone, or another diabetes drug. Wang et al. did note, however, that of the 29 articles that they found in which strongly recommended using pioglitazone rather than rosiglitazone, 25 were written by authors being paid by pioglitazone manufacturers.
In short, the evidence continues to mount that COI does bias physicians' judgment, even though an association cannot prove cause-and-effect. And it seems that once you start getting financial goodies from drug companies, it becomes less important exactly which companies paid you; you begin to see drugs generally in a favorable light and to minimize risks of adverse reactions.
Wang AT, McCoy CP, Murad MH, Montori VM. Association between industry affiliation and position on cardiovascular risk with rosiglitazone: cross sectional systematic review. BMJ 2010; 340:c1344, doi: 10.1136/bmj.c1344
To see what progress we have made since then, Dr. Amy T. Wang and colleagues in internal medicine at the Mayo Clinic decided to do a review of comments made after the publication of two major studies on rosiglitazone, one claiming that there was increased risk of heart attack, the other minimizing such risk. Their results have been published on line in BMJ (subscription required). (Hat tip to Dr. Roy Poses and the Health Care Renewal blog for mentioning this paper.)
Using careful statistical methods the authors first retrieved a set of papers (including editorials and letters to the editor as well as research studies) that cited the two initial studies. They did extensive searches to identify whether the authors had any COI with the makers of rosiglitazone, the makers of its major competititor drug, pioglitazone, or of any other oral diabetes drug. They then blindly classified the contents of each paper as positive/negative as to the heart attack risks of rosiglitazone and/or as recommending/not recommending its continued use.
Bottom line: even in this supposedly more enlightened age they found explicit COI statements in only 53% of the 202 papers they surveyed. The found authors with COI more than 3 times as likely to be positive about rosiglitazone or to recommend its use.
The results also argue against a rationalization sometimes heard by defenders of taking industry largesse--that if you take bribes from enough different companies, they all cancel out in the end. COI was associated with a greater likelihood of minimizing heart risk and recommending rosiglitazone whether the company from which the author had received payment manufactured rosiglitazone, pioglitazone, or another diabetes drug. Wang et al. did note, however, that of the 29 articles that they found in which strongly recommended using pioglitazone rather than rosiglitazone, 25 were written by authors being paid by pioglitazone manufacturers.
In short, the evidence continues to mount that COI does bias physicians' judgment, even though an association cannot prove cause-and-effect. And it seems that once you start getting financial goodies from drug companies, it becomes less important exactly which companies paid you; you begin to see drugs generally in a favorable light and to minimize risks of adverse reactions.
Wang AT, McCoy CP, Murad MH, Montori VM. Association between industry affiliation and position on cardiovascular risk with rosiglitazone: cross sectional systematic review. BMJ 2010; 340:c1344, doi: 10.1136/bmj.c1344
Into the Slammer: Only Answer for Pharma Misdeeds?
Now that our friend, Dr. Roy Poses over at the Health Care Renewal blog, has returned from a trip, I can put my feet up and go back to letting him write this blog for me.
Latest over his way is a post about King Pharmaceuticals having to pay a $42M penalty for a kickback scheme involving the long-acting morphine drug, Kadian:
http://hcrenewal.blogspot.com/2010/03/king-pharmaceuticals-settle-and-one.html
It's been mentioned numerous times that such penalties, that seem so massive to pore ol' folks like us and really are so piddly compared to the profits made by the big drug companies, can be treated by those companies simply as the cost of doing business and form no deterrent whatsoever to future misdeeds of the same sort. As Ann Woolner writes in Business Week, in a column cited by Health Care Renewal:
http://www.businessweek.com/news/2010-03-16/jail-time-for-executives-might-stop-drug-crimes-ann-woolner.html--
The biggest fine ever imposed in U.S. history, $2.3 billion against recidivist Pfizer, represented a mere 14 percent of the revenue stream from selling the drugs at issue over seven years.
So immune to criminal sanctions was the New York-based company that it launched its off-label Bextra campaign at the same time the company was pleading guilty to doing precisely the same thing with other drugs. The anti-inflammatory medication was later yanked from the market because of increased risk of heart attacks and stroke.
This leads Woolner to wonder what would work, which is the main point of the HCR blog post. The FDA could effectively shut down the drug company, which would throw a lot of innnocent people out of work in the middle of the recession and deprive patients of the useful drugs that company makes. A much better alternative, she says, is to note that while felony convictions of individuals--such as responsible company executives--are very difficult because you have to prove intend to defraud, the FDA is empowered by current law to engage in misdemeanor prosecutions, which require a much lower burden of proof. By those means, Woolner says, you might actually get some of the responsible parties to do a little jail time. And maybe that would grab the industry's attention in a way we have so far failed to do.
Latest over his way is a post about King Pharmaceuticals having to pay a $42M penalty for a kickback scheme involving the long-acting morphine drug, Kadian:
http://hcrenewal.blogspot.com/2010/03/king-pharmaceuticals-settle-and-one.html
It's been mentioned numerous times that such penalties, that seem so massive to pore ol' folks like us and really are so piddly compared to the profits made by the big drug companies, can be treated by those companies simply as the cost of doing business and form no deterrent whatsoever to future misdeeds of the same sort. As Ann Woolner writes in Business Week, in a column cited by Health Care Renewal:
http://www.businessweek.com/news/2010-03-16/jail-time-for-executives-might-stop-drug-crimes-ann-woolner.html--
The biggest fine ever imposed in U.S. history, $2.3 billion against recidivist Pfizer, represented a mere 14 percent of the revenue stream from selling the drugs at issue over seven years.
So immune to criminal sanctions was the New York-based company that it launched its off-label Bextra campaign at the same time the company was pleading guilty to doing precisely the same thing with other drugs. The anti-inflammatory medication was later yanked from the market because of increased risk of heart attacks and stroke.
This leads Woolner to wonder what would work, which is the main point of the HCR blog post. The FDA could effectively shut down the drug company, which would throw a lot of innnocent people out of work in the middle of the recession and deprive patients of the useful drugs that company makes. A much better alternative, she says, is to note that while felony convictions of individuals--such as responsible company executives--are very difficult because you have to prove intend to defraud, the FDA is empowered by current law to engage in misdemeanor prosecutions, which require a much lower burden of proof. By those means, Woolner says, you might actually get some of the responsible parties to do a little jail time. And maybe that would grab the industry's attention in a way we have so far failed to do.
Thursday, March 18, 2010
It Matters What We Call It
The Hastings Center, a bioethics and policy think tank, put out a news release today on a research study conducted by some of its people on bipolar disorder in children:
http://www.thehastingscenter.org/News/Detail.aspx?id=4567
The study reported the findings of a series of interdisciplinary workshops, and took a dim view of the recent tendency to liberally diagnose chaildren with behavioral problems as having bipolar disorder and treating them with powerful medications frequently used for adults. The report urges use of two newer diagnostic labels, Severe Mood Dysregulation (SMD) or Temper Dysregulation Disorder with Dysphoria (TDD). These, the investigators, say, really amount to "we don't know what causes this" and therefore tend to avoid prompting the use of unproven and potentially dangerous medications and other interventions.
In past posts I've noted the unholy alliance between drug industry marketing and a handful of academic psychiatrists who have been zealots for bipolar disorder in kids--such as: http://brodyhooked.blogspot.com/2009/03/lets-cut-dr-biederman-some-slack-just.html
The present report, however, notes an additional wrinkle that deserves comment: the workshop group universally agreed that “children and families can suffer terribly as a result of serious disturbances in children’s moods and behaviors,” and that these troubled children desperately need help. They also write, “It is a deeply regrettable feature of our current mental health and educational systems that some DSM diagnoses are better than others at getting children and families access to [needed] care and services.”
This, I think, is an excellent and underappreciated point. We often imagine that making a medical diagnosis is an objective, scientific, and completely apolitical exercise. In actuality, saying that somebody has disease X is almost always another way of saying, "I recommend that you treat this person in such-and-such a way." Often that amounts to a highly political statement, and in some environments, a very charged statement. (Witness the long fight over whether a group of sick veterans get to apply the term "Gulf War Syndrome" to whatever they have. We ought all of us to be able to agree, first, that these people have various illnesses; and second, that they deserve help for their illnesses. So just why, one might ask, does it become so very important exactly what this set of illnesses gets called? It is hard to avoid the answer that the issue is more political than scientific.)
If the problem exists for bodily illnesses, it exists in spades for mental illnesses. (And we can easily see why a group of vets would fight tooth and nail to establish the "reality" of Gulf War Syndrome if they thought that the only alternative diagnosis was, "it's all in your head.") Ideally, we should be ready to help people with all different sorts of mental illness at roughly a state of parity with our response to "physical" illness. In reality, we play favorites; those with some mental illnesses are seriously stigmatized and effectively denied good care, while those with some other mental illnesses get a variety of gains from the label they end up with.
So--take an illogical use of mental health diagnoses to create a set of winners and losers among those who end up with various different labels for whatever ails them, and then add the craziness of drug companies that want to market expensive drugs, regardless of what the evidence shows--and you have an especially toxic cauldron for causing harm to kids.
The impressive thing about media coverage of the zealot psychiatrists who drug these kids sometimes to death with multiple antipsychotic medications, is that each has the backing of a dedicated and vocal group of parents of their patients, who think they walk alongside God. Why? Because the psychiatrists agreed with the parents that their kids are indeed deeply disturbed, in ways that the parents did not cause and cannot understand. They then proceeded to try to help the kids, in however wrongheaded a way, with these drug cocktails--but one wonders if what made them heroes was not the "heroic" drug therapy so much as the simple, compassionate act of taking the parents seriously.
http://www.thehastingscenter.org/News/Detail.aspx?id=4567
The study reported the findings of a series of interdisciplinary workshops, and took a dim view of the recent tendency to liberally diagnose chaildren with behavioral problems as having bipolar disorder and treating them with powerful medications frequently used for adults. The report urges use of two newer diagnostic labels, Severe Mood Dysregulation (SMD) or Temper Dysregulation Disorder with Dysphoria (TDD). These, the investigators, say, really amount to "we don't know what causes this" and therefore tend to avoid prompting the use of unproven and potentially dangerous medications and other interventions.
In past posts I've noted the unholy alliance between drug industry marketing and a handful of academic psychiatrists who have been zealots for bipolar disorder in kids--such as: http://brodyhooked.blogspot.com/2009/03/lets-cut-dr-biederman-some-slack-just.html
The present report, however, notes an additional wrinkle that deserves comment: the workshop group universally agreed that “children and families can suffer terribly as a result of serious disturbances in children’s moods and behaviors,” and that these troubled children desperately need help. They also write, “It is a deeply regrettable feature of our current mental health and educational systems that some DSM diagnoses are better than others at getting children and families access to [needed] care and services.”
This, I think, is an excellent and underappreciated point. We often imagine that making a medical diagnosis is an objective, scientific, and completely apolitical exercise. In actuality, saying that somebody has disease X is almost always another way of saying, "I recommend that you treat this person in such-and-such a way." Often that amounts to a highly political statement, and in some environments, a very charged statement. (Witness the long fight over whether a group of sick veterans get to apply the term "Gulf War Syndrome" to whatever they have. We ought all of us to be able to agree, first, that these people have various illnesses; and second, that they deserve help for their illnesses. So just why, one might ask, does it become so very important exactly what this set of illnesses gets called? It is hard to avoid the answer that the issue is more political than scientific.)
If the problem exists for bodily illnesses, it exists in spades for mental illnesses. (And we can easily see why a group of vets would fight tooth and nail to establish the "reality" of Gulf War Syndrome if they thought that the only alternative diagnosis was, "it's all in your head.") Ideally, we should be ready to help people with all different sorts of mental illness at roughly a state of parity with our response to "physical" illness. In reality, we play favorites; those with some mental illnesses are seriously stigmatized and effectively denied good care, while those with some other mental illnesses get a variety of gains from the label they end up with.
So--take an illogical use of mental health diagnoses to create a set of winners and losers among those who end up with various different labels for whatever ails them, and then add the craziness of drug companies that want to market expensive drugs, regardless of what the evidence shows--and you have an especially toxic cauldron for causing harm to kids.
The impressive thing about media coverage of the zealot psychiatrists who drug these kids sometimes to death with multiple antipsychotic medications, is that each has the backing of a dedicated and vocal group of parents of their patients, who think they walk alongside God. Why? Because the psychiatrists agreed with the parents that their kids are indeed deeply disturbed, in ways that the parents did not cause and cannot understand. They then proceeded to try to help the kids, in however wrongheaded a way, with these drug cocktails--but one wonders if what made them heroes was not the "heroic" drug therapy so much as the simple, compassionate act of taking the parents seriously.
Sunday, March 14, 2010
Survey of Comparative Effectiveness Studies: Major Gaps
A paper and an editorial in the most recent JAMA (subscription required) depict the current status of comparative effectiveness research (CER). Drs. Conway and Clancy of DHHS/AHRQ summarize the findings in the paper by Drs. Hochman and McCormick of Harvard. The latter looked at the 6 highest-impact general and internal medicine journals between June 1, 2008 and September 30, 2009. They evaluated 328 studies that looked at medications, and found that 104 of them were CER. They noted at only 11% of these CER studies compared medications with nonpharmacologic interventions, while 31% compared different pharmacologic strategies. Another major gap was that only 19% of studies focused on safety of medications. Only 13% of the CER was commercially funded.
Conway and Clancy note that federal funding for CER has recently increased as a result of the economic stimulus package. They also suggest what steps must be taken in the future to get the most out of CER. I am certainly no expert in this field but to me, what their comments suggest is the need in CER for something like the international Cochrane Collaboration for systematic reviews of the medical literature. That is, a coordinating body or clearing house that can assure reasonably uniform and high-quality methods, and identify areas needing study and areas where overlapping studies may be underway, is highly desirable. They mention the Federal Coordinating Council for Comparative Effectiveness Research and the Institute of Medicine as possible locations for this activity.
One thing that Conway and Clancy did not mention perhaps deserves comment--they say nothing in their editorial about linking CER to issues of cost of care or cost-effectivess. This may reflect fears of the Obama Administration over stoking any talk of healthcare "rationing" as the fight over health reform legislation intensifies. For the record, Hochman and McCormick noted that only 2% of the studies they surveyed addressed cost-effectiveness.
Hochman M, McCormick D. Characteristics of published comparative effectiveness studies of medications. JAMA 303:951-958, 2010.
Conway PH, Clancy C. Charting a path from comparative effectiveness funding to improved patient-centered health care [editorial]. JAMA 303:985-986, 2010.
Conway and Clancy note that federal funding for CER has recently increased as a result of the economic stimulus package. They also suggest what steps must be taken in the future to get the most out of CER. I am certainly no expert in this field but to me, what their comments suggest is the need in CER for something like the international Cochrane Collaboration for systematic reviews of the medical literature. That is, a coordinating body or clearing house that can assure reasonably uniform and high-quality methods, and identify areas needing study and areas where overlapping studies may be underway, is highly desirable. They mention the Federal Coordinating Council for Comparative Effectiveness Research and the Institute of Medicine as possible locations for this activity.
One thing that Conway and Clancy did not mention perhaps deserves comment--they say nothing in their editorial about linking CER to issues of cost of care or cost-effectivess. This may reflect fears of the Obama Administration over stoking any talk of healthcare "rationing" as the fight over health reform legislation intensifies. For the record, Hochman and McCormick noted that only 2% of the studies they surveyed addressed cost-effectiveness.
Hochman M, McCormick D. Characteristics of published comparative effectiveness studies of medications. JAMA 303:951-958, 2010.
Conway PH, Clancy C. Charting a path from comparative effectiveness funding to improved patient-centered health care [editorial]. JAMA 303:985-986, 2010.
Friday, March 12, 2010
Do Bisphosphonates Increase Fracture Risk? Considerations to Keep in Mind
WARNING: This post contains relatively more speculation and less evidence. Toward the end I will make an evidence-based comment.
As I was driving to work this morning, the local radio news broadcast a spot about fears that long-term use of bisphosponates such as alendronate (Fosamax) might increase risks of fractures in certain locations, leading the FDA to consider new warnings. The natural reaction one might have to such news would be to pooh-pooh the idea that a drug that (supposedly) builds stronger bones could be a cause of bone weakness.
To see why this possibility might be more reasonable than would first appear, I'll refer you back to an excellent book that I have not mentiooned here in a while, John Abramson's Overdo$ed America, and its excellent chapter on osteoporosis. Dr. Abramson there reported data (which he admitted were preliminary and not conclusive) on the mechanisms by which bisphosponate drugs work.
He reminded us that there are basically two types of bone. If bones were PVC pipes, hollow, then the main type of bone would be cortical bone. The other type of bone, trabecular bone, is the internal part that provides the cross-bracing within the hollow tube. It does not take much engineering know-how to figure out that the real contributor to stronger, fracture-resistant bones is the trabecular component. It is therefore worrisome that studies suggest that bisphosphonates selectively increase cortical bone and in some circumstances might even disrupt growth of trabecular bone.
Now, if you are trying to make bones stronger, you'd want a drug that increases trabecular bone. But if your goal is to market drugs, you are very happy with a drug whose sole impact is on cortical bone. That's because bone-mineral-density (BMD) machines measure cortical bone more than they do trabecular bone. So if your marketing plan is to sell bisphosponate drugs by encouraging as many women as possible to go in for BMD testing-- see http://brodyhooked.blogspot.com/2009/12/npr-how-osteopenia-became-treatable.html-- then you want a drug that once women start taking it, makes their numbers look better soon.
As Dr. Abramson pointed out, this helps to explain why bisphosponates show very little if any effectiveness in preventing fractures in women with osteoporosis unless they have had a previous fracture, and why there is virtually no evidence that they help women with the less severe stage of bone density loss, osteopenia--and why there is even a chance that bisphosponates might increase fracture risk in some women with osteopenia.
So we don't know the final answer by any means, but as more news comes out about bisphosphonates and fracture risk, we should keep these possible underlying mechanisms in mind.
Evidence-based comment: This is yet another example of the flaws of using surrogate endpoints to determine whether or not to prescribe drugs. So long as we continue to believe that making BMD numbers look better is the same as preventing osteoporotic fractures, or that making blood sugar numbers look better in Type II diabetes is the same as preventing serious diabetic complications, then we are not practicing smart medicine; we're doing pharmaceutical industry marketing.
As I was driving to work this morning, the local radio news broadcast a spot about fears that long-term use of bisphosponates such as alendronate (Fosamax) might increase risks of fractures in certain locations, leading the FDA to consider new warnings. The natural reaction one might have to such news would be to pooh-pooh the idea that a drug that (supposedly) builds stronger bones could be a cause of bone weakness.
To see why this possibility might be more reasonable than would first appear, I'll refer you back to an excellent book that I have not mentiooned here in a while, John Abramson's Overdo$ed America, and its excellent chapter on osteoporosis. Dr. Abramson there reported data (which he admitted were preliminary and not conclusive) on the mechanisms by which bisphosponate drugs work.
He reminded us that there are basically two types of bone. If bones were PVC pipes, hollow, then the main type of bone would be cortical bone. The other type of bone, trabecular bone, is the internal part that provides the cross-bracing within the hollow tube. It does not take much engineering know-how to figure out that the real contributor to stronger, fracture-resistant bones is the trabecular component. It is therefore worrisome that studies suggest that bisphosphonates selectively increase cortical bone and in some circumstances might even disrupt growth of trabecular bone.
Now, if you are trying to make bones stronger, you'd want a drug that increases trabecular bone. But if your goal is to market drugs, you are very happy with a drug whose sole impact is on cortical bone. That's because bone-mineral-density (BMD) machines measure cortical bone more than they do trabecular bone. So if your marketing plan is to sell bisphosponate drugs by encouraging as many women as possible to go in for BMD testing-- see http://brodyhooked.blogspot.com/2009/12/npr-how-osteopenia-became-treatable.html-- then you want a drug that once women start taking it, makes their numbers look better soon.
As Dr. Abramson pointed out, this helps to explain why bisphosponates show very little if any effectiveness in preventing fractures in women with osteoporosis unless they have had a previous fracture, and why there is virtually no evidence that they help women with the less severe stage of bone density loss, osteopenia--and why there is even a chance that bisphosponates might increase fracture risk in some women with osteopenia.
So we don't know the final answer by any means, but as more news comes out about bisphosphonates and fracture risk, we should keep these possible underlying mechanisms in mind.
Evidence-based comment: This is yet another example of the flaws of using surrogate endpoints to determine whether or not to prescribe drugs. So long as we continue to believe that making BMD numbers look better is the same as preventing osteoporotic fractures, or that making blood sugar numbers look better in Type II diabetes is the same as preventing serious diabetic complications, then we are not practicing smart medicine; we're doing pharmaceutical industry marketing.
Monday, March 8, 2010
Getting a Pharm-Free Education: What Works?
A conversation has been going on recently on the Healthy Skepticism list-serv about how hard or how easy it is for physicians to stay up to date on new drugs and therapeutics without relying on sources that are controlled or heavily influenced by the pharmaceutical and device industries and their marketing juggernauts. Dr. Mark McConnell, who practices internal medicine in LaCrosse, WI, offered a set of highly practical tips that seemed too good not to share with all readers. He's given me permission to reproduce his how-to list, to which I have just a couple of additional suggestions.
Dr. McConnell states that by adhering to his program the necessary investment of time needed to stay reasonably informed and up to date is about 5-10 hours per month. (Like anything else, I'll add, when you just begin to start using any of these sources, it will take a bit longer; once you become used to how each works and where to locate the information you need, your time will shrink.) Dr. McConnell notes that he does not have a specific set-aside budget for CME and so he uses his own funds for these programs and sources.
His core resources:
Oakstone's Practical Reviews in internal medicine
$400/year
http://www.cmeonly.com/ME2/Audiences/dirmod.asp?sid=169BFEB1B46447C79F7F4D0B70D0253B&nm=Product+Catalog&type=Commerce&mod=GenComJournals&mid=63594F04C705480CA3E0A9BAAEE18D0E&AudId=920904C7329349CDA12AB2FB770606B1&tier=3&id=908141712AE34A799974F093EB52E0E6
InfoPOEMs from Essential Evidence Plus
$79/year
http://www.essentialevidenceplus.com/index.cfm
Therapeutic Initiatives Drug Therapy review course
$1000/year
http://www.ti.ubc.ca/node/14
Prescriber's Letter
$88/year
http://www.prescribersletter.com/(S(izxxzx45ukr2sobec3nt2sym))/home.aspx?cs=&s=PRL
I just have two additional resources to comment on. One is a service that provides a monthly CD with an audio presentation and evidence-based discussion of 40 recent articles pertinent to primary care, along with a database that allows you to store all 40 abstracts each month on your computer and later search them--Primary Care Medical Abstracts, http://www.ccme.org/PCMA/index-frame.html, $279/year. Rick Bukatra and Jerry Hoffman present, discuss, and argue about the abstracts in a manner somewhat reminiscent of "Car Talk" on NPR.
Second, I have been a long-time satisfied subscriber of The Medical Letter, http://www.medicalletter.org/, $98/year. This is supposed to be the Granddaddy of all U.S. non-commercially-sponsored publications on therapeutics, having been founded in 1959. The Medical Letter was being criticized on the HS list for not being truly independent and for allowing companies to review its assessments of their drugs. All I can say in defense of my longstanding use of this source (when I was in practice, which I am not currently) is that the publication hardly ever endorses a new drug, and most often says that a new drug is really no better than an older drug. The few times I have mentioned this publication to a drug rep, he has pooh-poohed it vigorously and given me numerous reasons why I should pay no attention. So if the drug companies are allowed to see the reviews, it does not appear that they have much influence over what is eventually published. I'd appreciate more discussion of this in the Comments.
None of the above sources accept ads from industry.
Dr. McConnell states that by adhering to his program the necessary investment of time needed to stay reasonably informed and up to date is about 5-10 hours per month. (Like anything else, I'll add, when you just begin to start using any of these sources, it will take a bit longer; once you become used to how each works and where to locate the information you need, your time will shrink.) Dr. McConnell notes that he does not have a specific set-aside budget for CME and so he uses his own funds for these programs and sources.
His core resources:
Oakstone's Practical Reviews in internal medicine
$400/year
http://www.cmeonly.com/ME2/Audiences/dirmod.asp?sid=169BFEB1B46447C79F7F4D0B70D0253B&nm=Product+Catalog&type=Commerce&mod=GenComJournals&mid=63594F04C705480CA3E0A9BAAEE18D0E&AudId=920904C7329349CDA12AB2FB770606B1&tier=3&id=908141712AE34A799974F093EB52E0E6
InfoPOEMs from Essential Evidence Plus
$79/year
http://www.essentialevidenceplus.com/index.cfm
Therapeutic Initiatives Drug Therapy review course
$1000/year
http://www.ti.ubc.ca/node/14
Prescriber's Letter
$88/year
http://www.prescribersletter.com/(S(izxxzx45ukr2sobec3nt2sym))/home.aspx?cs=&s=PRL
I just have two additional resources to comment on. One is a service that provides a monthly CD with an audio presentation and evidence-based discussion of 40 recent articles pertinent to primary care, along with a database that allows you to store all 40 abstracts each month on your computer and later search them--Primary Care Medical Abstracts, http://www.ccme.org/PCMA/index-frame.html, $279/year. Rick Bukatra and Jerry Hoffman present, discuss, and argue about the abstracts in a manner somewhat reminiscent of "Car Talk" on NPR.
Second, I have been a long-time satisfied subscriber of The Medical Letter, http://www.medicalletter.org/, $98/year. This is supposed to be the Granddaddy of all U.S. non-commercially-sponsored publications on therapeutics, having been founded in 1959. The Medical Letter was being criticized on the HS list for not being truly independent and for allowing companies to review its assessments of their drugs. All I can say in defense of my longstanding use of this source (when I was in practice, which I am not currently) is that the publication hardly ever endorses a new drug, and most often says that a new drug is really no better than an older drug. The few times I have mentioned this publication to a drug rep, he has pooh-poohed it vigorously and given me numerous reasons why I should pay no attention. So if the drug companies are allowed to see the reviews, it does not appear that they have much influence over what is eventually published. I'd appreciate more discussion of this in the Comments.
None of the above sources accept ads from industry.
Subscribe to:
Posts (Atom)