Association of American Medical Colleges issues task force report on industry funding of medical education

The Association of American Medical Colleges (AAMC) recently issued a 43-page report of its task force on industry funding of medical education. Sections of the report deal with site access by pharmaceutical company representatives.

Specifically, the report states that “to protect patients, patient care areas, and work schedules, access by pharmaceutical representatives to individual physicians should be restricted to non-patient care areas and nonpublic areas… and should take place only by appointment with or invitation of the physician.”

The report goes on to state that highly trained industry reps with a PhD, MD,or PharmD are best suited for conveying science and pharmaceutical information in academic medical centres… and that this also should be by invitation only.

Moreover, industry-supplied food or meals are to be considered personal gifts and will not be permitted; and travel funds, other than for contractual services or legitimate reimbursement are not allowed. Finally, on the subject of drug samples, the report states that these may be of some benefit… but that physicians may run the risk of conflict of interest if they are seen to profit from recommending certain products.

Of course, these proscriptions are not new. The pharmaceutical industry and its watchdog organisation the Pharmaceutical Research and Manufacturers Association (PhRMA) have tried to curb the excesses of trinkets and junkets being offered as blandishments to the medical profession. In fact, PhRMA recently issued a new ‘Code on Interactions with Healthcare Professionals‘ that bans giveaways like pens, notepads and coffee cups with company logos, and meals in restaurants. The code also calls for caps on how much companies can pay physicians for speaking engagements. While firms such as Pfizer, J & J, Eli Lilly and GSK have unanimously endorsed the code, the Wall Street Journal suggests that some critics claim that it will do little to curb industry influence on doctors. But the AAMC task force report appears to put some teeth in the rulings.

So, are there ways to get around these new rules? Well, Health Outcomes Communicator ( HOC ) was among the first to call attention to alternative ways by which pharmaceutical companies can reach physicians. In an article in the December 2007 issue of HOC titled “A new way for pharmaceutical companies and prescribers to interact,” we published an interview with the founder and CEO of Sermo, Dr Daniel Palestrant. Sermo, he told us, is an internet-based social networking site for physicians. Pfizer, which had laid off 20% of its US and European sales teams, quickly saw Sermo as a way to communicate with doctors online and provide them with drug and disease information. Sermo, said Palestrant, provides the technology to change the way industry and the medical profession talk to each other.

HOC , as its lead page proclaims each issue, is not only about ‘information and ideas for health economists;’ it’s also about being at the cutting edge of both.

Training programmes: Where do future health economists come from?

For those interested in entering or advancing in the field of health economics and outcomes research, and for those looking for newly-minted researchers to employ, it would help to know where training for the field is available. An online search, by no means exhaustive, turned up quite a variety of schools, universities, and organisations offering educational opportunities.

The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) provides a list of university degree programmes, by country, with contact information and web links. The list shows 38 universities in the United States, 8 in the United Kingdom, 5 in France, 3 in Canada, 2 each in Germany and the Netherlands, and 1 each in Hong Kong, Italy, Spain, and Thailand. Most of the programmes are at the master’s-degree level. ISPOR also has a network of Student Chapters at many of these universities.

Health Economics education presents an online list of universities in the United Kingdom and elsewhere that offer elective health economics modules in undergraduate and MSc programmes. It also lists medical schools that offer health economics in the medical curriculum. This site is under development, so it promises to grow in utility.

The International Health Economics Association presents fairly detailed information on current educational programmes. Categories of information include distance learning, master’s, PhD, postgraduate/non-degree, seminars, short courses, and undergraduate education.

The website www.healtheconomics.com also offers information and links to a variety of resources for health economics education. In addition to degree programmes, it includes books, audio programmes, databases, journals, libraries, government agencies, seminars and workshops, and pharma/biotech companies. The founder and president of healtheconomics.com is Patti Peeples, RPh, PhD, the focus of this month’s “HOC people”.

Health Economics Digest offers e-learning courses on introductory health economics subjects such as PROs, health economics concepts, health economics methodology, comparative effectiveness and evidence based medicine and demonstrating the value of health care. For introductory courses, they cover all the elements in easy to understand modules. The delivery is excellent too as it allows users to login and save where they are up to and re-visit at a later date.

The sources cited are good places to start for anyone wishing to learn more about health economics education. They provide current information and appear to be growing with the field.

Book review: Prevention effectiveness – 2nd edition

This text is required reading for students in my introductory cost-effectiveness course. Why? Because it combines a discussion of the United States Panel on Cost-Effectiveness in Health and Medicine’s recommendations, general readability, and an introduction to decision analysis.

First, for most students in an introductory course, knowing what the US Panel’s recommendations were and that they were the result of well-reasoned debate is sufficient. The US recommendations are likely to remain relevant to US audiences as they have been the only federal government-based recommendations.

Second, the Haddix et al. text is readable.

Third, the book provides an introduction to decision analysis, an integral part of many cost-effectiveness studies in the literature.

Finally, this is a useful text for an introductory cost-effectiveness course for anyone with no decision analysis background who needs to be aware of US recommendations.

How to use visual images when explaining QALYs

Before lecturing on quality adjusted life years (QALYs) you should carefully consider the most appropriate way to educate an audience.

The most obvious visual image related to QALYs is the graph of health utility over time. However, health economists called upon to give one-shot lectures to clinical audiences should not limit the visual images they employ to these standard graphs. The use of visual images relevant to clinicians’ day-to-day professional lives can facilitate communication.

Imagine discussing a series of syringes, flasks, and vats to illustrate the aggregation health-related quality of life over time and among individuals.

To begin illustrating the concept of measuring health related quality of life, you could ask members of a clinical audience to imagine filling a 10mL syringe in proportion to their personal feeling about health-related quality of life on the day of the lecture. When comparing different individuals, syringes filled with more liquid represent a higher quality of life for that individual.

To characterise health-related quality of life over a year, you might ask members of your audience to imagine filling a syringe each day. At the end of the year, the contents of all 365 syringes are emptied into a single flask that measures 3.65L of liquid when full.

The number of QALYs experienced by the individual in a year would be the fraction of the flask that is full. Many different sequences of syringe levels (i.e. daily quality of life) can yield the same total amount of liquid after a year.

The calculation of QALYs cannot distinguish among these sequences. The fact that the sequence of health-related quality of life experiences during a year does not affect the QALYs that are calculated is the key insight regarding aggregation over time for an individual.

Then, imagine a population of 100 individuals, each of whom has filled some fraction of a 3.65L flask. The QALYs experienced by the population (an important component of a cost-effectiveness analysis) can be measured by emptying all 3.65L flasks into a 365L vat.

The fraction of the vat that is full measures the average QALYs experienced. The key insight for aggregation at this stage is that the distribution of QALYs among members of the population is not considered.

An economist who wants to facilitate understanding of cost-effectiveness and QALYs should take advantage of the opportunity to be creative, or even light-hearted, when choosing visual images to use in a lecture. The images must meet two primary criteria: being appreciated by the audience and being easily explained by the economist.