Management of Conflict of Interest Issues in the Activities of the American Heart Association Emergency Cardiovascular Care Committee, 2000–2005
In 2000 the American Heart Association (AHA), in conjunction with the International Liaison Committee on Resuscitation (ILCOR), sponsored the International Guidelines 2000 Conference on CPR and ECC. This conference led to the publication of the first international guidelines on CPR and ECC, Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: An International Consensus on Science.1 The conflict of interest (COI) policies governing the 2000 evidence discovery and consensus development process were consistent with the general COI policies in effect in the AHA at that time. Although these policies addressed disclosure and abstention from voting during subcommittee deliberations, they were, in retrospect, not sufficiently detailed to address the unique circumstances of a worldwide scientific review and consensus development process. In addition, they did not provide specific guidance for management of conflicts that arose among science reviewers, panelists, guidelines authors, and others involved in the complex guideline development process.
After publication of the ECC Guidelines 2000, the AHA was criticized for its management of potential conflicts among participants,2 particularly those participants who received industry support for research or consultation. An intense debate took place in the literature, news sections of scientific journals, and Internet chatrooms. The AHA contended that the rigor of the scientific review and the multilayered peer-review process ensured that the guidelines were unbiased and that no individual or group could unduly influence guideline recommendations.
In preparation for the 2005 evidence evaluation process, the AHA Emergency Cardiovascular Care Committee began plans to create a new, more intensive, and more explicit approach to COI management and disclosure. The committee believed that public trust in the integrity of the scientific review process was so important that improvements were needed even if the existing safeguards had been effective. Therefore, in 2001 ECC leaders began broad discussions among the subcommittees about optimal management of conflicts of interest. These discussions continued at every meeting of the ECC Committee and its subcommittees from 2001 until the present.
In 2002 the ECC Committee invited Allan Detsky, an expert on the impact of commercial relationships on guideline development,3 to discuss the risks of undisclosed and unmanaged conflicts. In addition, one of the authors of this editorial (J.B.) met with Sheldon Krimsky, author of Science in the Private Interest,4,5 to review possible strategies to minimize potential commercial and intellectual conflicts. In addition to these discussions, about 100 AHA ECC committee and subcommittee volunteers responsible for setting policy and developing scientific consensus had multiple opportunities, in both formal and informal discussions, to consider optimal management of conflicts of interest and its effect on the guideline process. It was the consensus of this ECC leadership group that it was possible to design and implement a process to ensure that the AHA ECC review of science and development of guideline recommendations were truly and visibly free of commercial influence.
In 2002 the ECC Committee endorsed the Policy and Procedures for Disclosure and Management of Potential Conflict of Interest, which can be accessed on the AHA website: http://www.c2005.org. From that point forward all AHA ECC meetings were conducted in compliance with this policy and with routine AHA COI policies. Issues were brought to committee and task force chairs for resolution or sent to a higher level for decision.
In anticipation of the 2005 Consensus Conference, AHA volunteers worked with their international counterparts in ILCOR to develop a similar policy to govern all activities related to the 2005 evidence evaluation process. In 2004 ILCOR adopted a policy consistent with the AHA ECC policy, available at: http://www.c2005.org. All ILCOR meetings and activities since that time have complied with that policy, which governs all aspects of the evidence evaluation process, including selection of resuscitation topics for review, selection of worksheet authors to research the topics, presentation of findings in preliminary meetings and at the 2005 Consensus Conference, and drafting of consensus statements. ILCOR appointed two COI cochairs (J. Billi and D. Zideman) to oversee the process, adjudicate issues, and recommend solutions when problems arose.
The 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations presented a special challenge to management and disclosure of conflicts of interest. How could an audience remain continuously aware of the industry relationships of a speaker in a way that would allow listeners to keep those relationships in mind while weighing comments? ILCOR chose an approach to disclosure that, to our knowledge, has never been used before. For the duration of every speaker’s comments, the speaker’s COI disclosure slide was projected on a screen separate from the screen used to display presentation slides. This practice was followed for all scheduled speakers, panelists, and moderators as well as for anyone who asked questions or made comments from the floor. The disclosure slide listed research sponsored by industry, consultancies, paid speakers bureau roles and lectureships, gifts, investments, patents, and other relationships with the potential to influence the speaker. This novel disclosure method is described in detail in another editorial.6 For the most part, participants responded favorably to the disclosure method, which was quick, unobtrusive, and uniform and offered the added benefit of reminding the audience of the speaker’s name, especially important for speakers from the floor.
Although the COI management policies and practices used in 2005 by the AHA and ILCOR set a new standard for COI management and disclosure, the AHA and the rest of the scientific community should not yet be satisfied. Because substantial industry investment is often needed for scientific discovery and the invention of new technologies, those who commit to evidence review and development of guidelines must remain vigilant for new relationships that could pose a problem or the appearance of a conflict. The fact that most commercial relationships might not actually influence the scientists involved in the research or the review does not remove the potential for the public to be rightfully concerned about potential bias. The integrity of our current and future consensus statements and guidelines depends on the public trust. We must work to continue to earn it year after year.
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
American Heart Association in collaboration with International Liaison Committee on Resuscitation. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2000; 102 (suppl): I1–I384.
Kassirer J. On the Take: How Medicine’s Complicity with Big Business Can Endanger Your Health. New York, NY: Oxford University Press; 2004.
Krimsky S. Science in the Private Interest: Has the Lure of Profits Corrupted Biomedical Research? Lanham, Maryland: Rowman and Littlefield Publishers, Inc.; 2003.
Billi JE, Zideman D, Eigel B, Nolan J, Montgomery W, Nadkarni V, from the International Liaison Committee on Resuscitation (ILCOR) and American Heart Association (AHA). 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Editorial: Conflict of interest management before, during and after the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2005; 112: III-131–III-132.