Correspondence

Publication of Sponsored Symposiums in Medical Journals

N Engl J Med 1993; 328:1196-1198April 22, 1993

Article

To the Editor:

The Coalition of Healthcare Communicators takes exception to the article by Bero et al (Oct. 15 issue).1 Their research seems to be centered on the supposition of some in academia today that if industry is involved it must be a bad thing. The authors use arbitrary measures to judge the purity of editorial material generated by seminars and symposiums funded by the pharmaceutical industry. For example, readers are asked to accept their judgment of what is a “misleading title,” with only one debatable example provided. It is also important to note that the Accreditation Council for Continuing Medical Education allows the use of pharmaceutical brand names within the context of a balanced program in which a number of products are mentioned. Otherwise, the organization thought the educational value of the program would be limited, because physicians often do not recognize products by their generic names.

I suggest the following questions as more appropriate for evaluating sponsored symposiums for publication: Is the information truthful? Is it fair and balanced? Does the material increase the reader's base of information? Is there evidence that after reading a supplement, doctors will prescribe drugs that are inappropriate, expensive, or both? And finally, Does the use of a pharmaceutical brand name in the symposium in and of itself make the information in the symposium misleading?

Jack E. Angel
Coalition of Healthcare Communicators, Greenwich, CT 06830

1 References

1. 1

   Bero LA, Galbraith A, Rennie D. The publication of sponsored symposiums in medical journals. N Engl J Med 1992;327:1135-1140
   Full Text | Web of Science | Medline

To the Editor:

Several years ago, we sent a questionnaire to the corresponding authors of all the clinical trials dealing with the medical therapy of angina pectoris that were published over a three-year period in eight major peer-reviewed journals of cardiology and internal medicine.1 The questions dealt with the prevalence of funding by the pharmaceutical industry for these studies, and whether the source of funding affected the publication process. Responses were obtained from authors of 82 of the 91 articles identified.

In 72 percent of the studies, pharmaceutical companies were either the primary or the secondary mechanism of funding, but this was acknowledged in only 27 percent of these studies. In contrast, although governmental funding (from the National Institutes of Health or the Department of Veterans Affairs) was involved in only 20 percent of the studies, such funding was acknowledged in 33 percent of the manuscripts. It is noteworthy that when a reviewer unaware of the source of funding reviewed the manuscripts, a higher proportion of the industry-funded studies were classified as adequately controlled and designed (71 percent, vs. 33 percent for studies not funded by pharmaceutical firms; P<0.01). The conclusions of the studies were considered to be justified by the data in similar proportions (95 percent and 89 percent, respectively).

A distinctive feature of the industry-supported studies was that 48 percent were published in symposiums, as compared with 26 percent of the other studies. The source of funding of the 34 industry-sponsored studies published in symposiums was never cited in the article itself (and thus would not be available to readers of reprints). This information was included in the introduction to the symposium or elsewhere in the journal in only 54 percent of the cases.

Few articles published in symposiums were peer-reviewed in the normal manner: 12 percent were not reviewed, 29 percent were reviewed only by a guest editor, and 47 percent were reviewed by people selected by the guest editor. The high rate of multiple publication of a single study was also troublesome; 56 percent of the articles based on studies with industrial sponsorship and 71 percent of the articles published in symposiums represented duplicate publications. Only rarely was previous publication of the same material acknowledged directly.

We agree with the recommendations of Bero et al. that pharmaceutical companies, journal editors, and authors must all share the responsibility of providing the reader with all the information required to read symposiums and other scientific publications critically.

Barry M. Massie, M.D.
Veterans Affairs Medical Center, San Francisco, CA 94121

Daniel Rothenberg, B.A.
University of Chicago, Chicago, IL 60637

1 References

1. 1

   Massie BM, Rothenberg D. Impact of pharmaceutical industry funding of clinical research: results of a survey of antianginal trials. Circulation 1984;70:Suppl II:390-390 abstract.
   Web of Science

To the Editor:

It appears that Bero et al. were not blinded to the category of publication or sponsorship when they read the studies they discuss. This might not be expected to alter the categorization of the “hard” results (the number of drugs involved or the number of times a trade name was cited), but it certainly could affect the interpretation of a subjective category, such as “misleading title.” I would argue that the results are unnecessarily weakened by the failure to prevent this potential source of bias. This deficiency is especially unfortunate because I have no doubt that the results would have survived greater methodologic rigor.

Mark S. Roberts, M.D., M.P.P.
Deaconess Hospital, Boston, MA 02215

To the Editor:

Bero et al. list recommendations for reducing the number of symposiums sponsored and biased by pharmaceutical companies that are published. That is the tip of the iceberg. It is very difficult nowadays for an academic physician to organize a neutral symposium. In fields such as mine (hematology), audiences have come to expect that a symposium will be free and, indeed, that a free meal will be thrown in and perhaps also travel expenses. Learned societies charge fees (I have been quoted figures of $10,000 and up) for permitting an independent symposium to be held the day before or after their annual meetings in one of the hotels secured for meeting guests and for mentioning the symposium in their meeting announcement. Nearly all these expensive slots are bought by pharmaceutical companies (who else can afford them?), and most of the agendas are self-serving. A number of symposiums are run simultaneously, creating a major money-making opportunity for the societies and freezing out poorer but neutral organizers who want to spare the potential audience the expense and inconvenience of going to an independent symposium at another time and place.

Carol K. Kasper, M.D.
Orthopaedic Hospital, Los Angeles, CA 90007

To the Editor:

Bero et al. note the promotional characteristics of many symposiums sponsored by drug companies that are published in medical journals. Indirect evidence of the promotional usefulness of symposiums can be found elsewhere in the same issue of the Journal (Oct. 15, 1992). In that issue 25 advertisements are at least a page long. Of these, 14 cite references. (A 15th contains a bibliography with one item, but no reference to it in the ad.) Ten of the 14 ads with references include symposiums sponsored by drug companies among their references.

Thomas E. Finucane, M.D.
Francis Scott Key Medical Center, Baltimore, MD 21224

Author/Editor Response

The authors reply:

To the Editor: Mr. Angel represents a coalition of pharmaceutical advertisers, public relations groups, and marketers. Therefore, he is primarily concerned with protecting advertising, which we suspect many symposiums of being, rather than the integrity of the medical literature. Though blinding would have strengthened our study design, as Roberts comments, the data on misleading titles were the only subjective measurements. Our list of 67 misleading titles was provided to the editors and reviewers before publication, and to the readers through the National Auxiliary Publications Service. We emphasize that our findings that symposiums often lack peer review and focus on single drugs that are unapproved or of low therapeutic gain are far more important than our misleading titles.

The Accreditation Council for Continuing Medical Education may indeed approve the use of brand names within a “balanced program in which a number of products are mentioned,” but our finding that 26 percent of symposiums focused on a single drug shows that many programs were not balanced. The use of brand names does not necessarily suggest that a symposium is misleading, but their use is associated with a lack of peer review. We are investigating the quality and usefulness of symposiums sponsored by the drug industry as a follow-up to our descriptive study.

The interesting data of Massie and Rothenberg corroborate our results and strengthen our recommendations that the identity of the sponsor and the type of review should be disclosed for symposiums and references to symposiums. Dr. Kasper's letter shows how symposiums seem often to be driven by money. We are impressed by the $90 million a year spent by the drug industry on symposiums,1 a large proportion of which feature “me-too” drugs. Physicians' prescribing practices are known to be altered by exposure to drug representatives and their handouts, which include symposium reprints2. We do not know how these symposiums affect the appropriateness of prescribing, but Dr. Finucane's observation suggests that there is a direct link between advertising and symposiums. The frequent citation of symposiums in drug advertisements offers an additional reason for readers to be skeptical of reprints from supplements and for the Food and Drug Administration to be concerned about symposiums. We now have the additional worry that consensus conferences may be used by drug companies to disseminate their views3.

We do not imply that drug-company sponsorship in and of itself is evil, but it is if the money affects the integrity of the academic speakers, their societies, journals, or attendees.

Lisa A. Bero, Ph.D.
Alison Galbraith, B.A.
Drummond Rennie, M.D.
University of California, San Francisco, CA 94109

3 References

1. 1

   United States Senate Committee on Labor and Human Resources. Advertising, marketing and promotional practices of the pharmaceutical industry. Washington, D.C.: Government Printing Office, 1991. (Senate hearing 101-1217).
   

2. 2

   Avorn J, Chen M, Hartley R. Scientific versus commercial sources of influence on the prescribing behavior of physicians. Am J Med 1982;73:4-8
   CrossRef | Web of Science | Medline

3. 3

   Sheldon TA, Smith GD. Consensus conferences as drug promotion. Lancet 1993;341:100-102
   CrossRef | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   Richard Jones, Stuart Younie, Andrew Macallister, Jim Thornton. (2010) A comparison of the scientific quality of publicly and privately funded randomized controlled drug trials. Journal of Evaluation in Clinical Practice 16:6, 1322-1325
   CrossRef

2. 2

   Alphonso Brown, Daniel Kraft, Sara M. Schmitz, Virginia Sharpless, Christopher Martin, Ritesh Shah, Nicholas J. Shaheen. (2006) Association of Industry Sponsorship to Published Outcomes in Gastrointestinal Clinical Research. Clinical Gastroenterology and Hepatology 4:12, 1445-1451
   CrossRef

3. 3

   A WAZANA, F PRIMEAU. (2002) Ethical considerations in the relationship between physicians and the pharmaceutical industry. Psychiatric Clinics of North America 25:3, A647-A663
   CrossRef