Letters

1. Schouten HJ, Geersing GJ, Koek HL, et al. Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis. BMJ. 2013;346:f2492. 2. Andro M, Righini M, Le Gal G. Adapting the D-dimer cutoff for thrombosis detection in elderly outpatients. Expert Rev Cardiovasc Ther. 2013;11(6):751-759.

Potential Conflicts of Interest for Academic Medical Center Leaders To the Editor In their Research Letter, Dr Anderson and colleagues1 identified academic medical center (AMC) leaders who served on the boards of directors of pharmaceutical companies and warned of potential conflicts of interest without providing any data to suggest there is a problem. Society is well served when corporations have diverse boards, dominated by outside board members with voting power, to provide strategic direction and oversight and bring the totality of their experiences to bear on the organization. I am puzzled by the statement of Anderson et al1 regarding dual leadership roles and the inadequacy of internal disclosure rules because the roles of AMC leaders must be publicly disclosed by the company as well as assessed and found not to represent a conflict of interest at each individual AMC. In fact, senior, respected AMC leaders are invaluable to furthering the mission of pharmaceutical companies to discover and develop new medicines to treat disease and prolong life. Their advice and input in this process result in better medicines than would be possible without their input. Who better to advise companies with this mission than those leaders of institutions that seek to combine research, teaching, and clinical care for this same goal?

cial functions. The companies are obligated to maximize profits for owners and shareholders. In contrast, AMCs have a moral commitment to serve the public interest before their own. Although not always met, this commitment involves professional education, research (basic and applied), and state-of-the-art medical care that is always available even when unprofitable. The faculty of AMCs should also be a major resource for the objective evaluation of the clinical safety and effectiveness of the pharmaceutical industry’s products. No individual can simultaneously serve as a leader in both these institutions without compromising obligations to one or both. Collaboration between AMCs and companies is sometimes necessary for the development of new drugs, but this should never personally involve AMC leadership and should always be strictly regulated. Now, more than ever, it is important that leaders in AMCs set an example for students and faculty by concentrating on advancing the not-for-profit social purposes of these institutions. They cannot do this if they also have ties to pharmaceutical businesses. Arnold S. Relman, MD Author Affiliation: Cambridge, Massachusetts. Corresponding Author: Arnold S. Relman, MD, 13 Ellery Sq, Cambridge, MA 02138 ([email protected]). Conflict of Interest Disclosures: The author completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported that he was a professor emeritus of medicine and social medicine at Harvard Medical School and former editor in chief of the New England Journal of Medicine. Additional Information: Dr Relman died June 17, 2014. 1. Anderson TS, Dave S, Good CB, Gellad WF. Academic medical center leadership on pharmaceutical company boards of directors. JAMA. 2014;311(13): 1353-1355.

John C. Lechleiter, PhD Author Affiliation: Eli Lilly and Company, Indianapolis, Indiana. Corresponding Author: John C. Lechleiter, PhD, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN 46285 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported that he is chairman, president, and CEO of Eli Lilly and Company; and a full-time employee and shareholder. 1. Anderson TS, Dave S, Good CB, Gellad WF. Academic medical center leadership on pharmaceutical company boards of directors. JAMA. 2014;311(13): 1353-1355.

To the Editor Dr Anderson and colleagues1 reported that leaders in many AMCs received substantial annual compensation for serving on the boards of pharmaceutical companies. Regardless of the form and amount of the compensation; whether it is retained by the individual AMC leader or donated to the AMC or to charity; whether it is fully disclosed; and no matter what the good intentions of the leaders might have been in accepting an affiliation with a pharmaceutical company, such ties are a real (never a “potential”) conflict of interest and should be totally eliminated. Academic medical centers and pharmaceutical companies are quite different institutions, with largely different so558

In Reply The goal of our study was to raise awareness about the prevalence of a type of financial relationship that, despite its magnitude, has received far less attention than the issue of free pens. We agree with Dr Lechleiter that both pharmaceutical companies and society are well served in being advised by academia. Yet, as Dr Relman points out, holding a board membership position places an obligation on an individual that goes beyond advising. It is clear that both companies and AMCs overlap in their mission to advance medical practice and patient care, yet Lechleiter omits and Relman highlights the equally compelling mission of for-profit companies to increase shareholder profits. As Relman states, holding contractually binding responsibilities to 2 entities creates a clear, not potential conflict of interest, so long as the mission of an academic institution is not identical to that of the company shareholders. Many advances in modern medicine have resulted from academic and industry collaboration, primarily in collaborative research efforts. However, the extent to which individuals who hold coexisting leadership positions in industry and academic medicine have fostered these beneficial partnerships has not been demonstrated.

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Letters

Lechleiter suggests that internal disclosure is an adequate safeguard for the conflict posed by holding a company directorship; however, the Institute of Medicine1 and most recently individual academic leaders2 have raised concerns over the limitations of disclosure, particularly because it may be unrealistic to expect hospital employees to weigh in on the conflicts of those to whom they report. Leading AMCs have pursued limitations on the financial relationships of senior leadership,3 whereas some have suggested a wider variety of management strategies.2,4 Alternative advisory roles that avoid creating a fiduciary responsibility to shareholders (eg, paid or unpaid consulting engagements) would allow industry to secure the invaluable guidance from AMC leaders, which Lechleiter emphasizes, while minimizing the competing responsibilities. Timothy S. Anderson, MD Chester B. Good, MD, MPH Walid F. Gellad, MD, MPH Author Affiliations: Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Anderson); Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (Good, Gellad). Corresponding Author: Walid F. Gellad, MD, MPH, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, 151C University Dr, Pittsburgh, PA 15240 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Anderson reported receiving travel reimbursement from the American Medical Student Association for speaking on conflict of interest topics. Dr Gellad reported receiving research funding through RAND from Express Scripts for work unrelated to the study. Dr Good reported having no disclosures. 1. Institute of Medicine. Conflict of interest in medical research, education, and practice. April 21, 2009. http://www.iom.edu/Reports/2009/Conflict-of -Interest-in-Medical-Research-Education-and-Practice.aspx. Accessed May 7, 2014. 2. Pisano ED, Golden RN, Schweitzer L. Conflict of interest policies for academic health system leaders who work with outside corporations. JAMA. 2014;311(11): 1111-1112. 3. Wilson D. Harvard teaching hospitals cap outside pay. New York Times. January 2, 2010. http://www.nytimes.com/2010/01/03/health/research/03hospital.html ?_r=2&. Accessed May 7, 2014. 4. Lo B. Serving two masters—conflicts of interest in academic medicine. N Engl J Med. 2010;362(8):669-671.

Ending the Sale of Cigarettes at US Pharmacies To the Editor Drs Brennan and Schroeder1 are not the first to suggest that selling cigarettes in US pharmacies normalizes smoking by sending the message that smoking “cannot be all that unhealthy” if health-related facilities are selling them. However, paradoxically, an alternative approach to reducing access to tobacco and denormalizing smoking could be to legally limit tobacco sales only to pharmacies (and ban the sales of tobacco products from all other retail outlets). There are several potential advantages of such an approach. First, allowing tobacco sales only in pharmacies would reduce the number of tobacco outlets, thereby reducing access to and visibility of tobacco. For example, in New Zealand, this action would lead to an approximate 80% reduction in the total number of tobacco retail outlets (from around 5000 outlets2 to about 9803).

Second, pharmacists could potentially offer every tobacco customer brief smoking cessation advice and cessationassisting pharmaceuticals, thereby fulfilling their role of health professional rather than contradicting it. This is consistent with the provision of other health-related advice by pharmacists in public health programs. For example, pharmacists in some settings participate in needle or syringe exchange programs for injection drug users, providing clean needles and offering professional advice.4 At least one jurisdiction is exploring this approach. The government of Iceland is considering banning the sale of tobacco products at all retail outlets and making tobacco available by prescription only at pharmacies.5 Such a strategy could fit well into a more comprehensive tobacco endgame strategy including regular, large tobacco tax increases, intensive mass media campaigns, and the phased reduction of nicotine levels in tobacco. Frederieke S. van der Deen, BSc, MSc Amber L. Pearson, MSc, MPH, PhD Nick Wilson, MBChB, DIH, MPH Author Affiliations: Department of Public Health, University of Otago, Wellington, New Zealand. Corresponding Author: Frederieke S. van der Deen, BSc, MSc, Department of Public Health, University of Otago, Wellington, PO Box 7343, Wellington, New Zealand ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Brennan TA, Schroeder SA. Ending sales of tobacco products in pharmacies. JAMA. 2014;311(11):1105-1106. 2. Marsh L, Doscher C, Robertson LA. Characteristics of tobacco retailers in New Zealand. Health Place. 2013;23:165-170. 3. Ministry of Health. Facility code table. http://www.health.govt.nz/nz-health -statistics/data-references/code-tables/common-code-tables/facility-code -table. Accessed May 19, 2014. 4. Nacopoulos AG, Lewtas AJ, Ousterhout MM. Syringe exchange programs: impact on injection drug users and the role of the pharmacist from a US perspective. J Am Pharm Assoc (2003). 2010;50(2):148-157. 5. Pidd H. What a drag … Iceland considers prescription-only cigarettes. http://www.theguardian.com/world/2011/jul/04/iceland-considers -prescription-only-cigarettes. Accessed March 24, 2014.

To the Editor Many people believe that health-promoting businesses should stop selling tobacco products.1,2 As Drs Brennan and Schroeder3 reported, CVS Caremark has announced a welcome change in this direction. The readiness of similar companies to follow suit is unknown. Perhaps such movement can be shareholder driven; precedent exists for such an approach.4 Alternatively, tax breaks may be an incentive. It seems reasonable to formally recognize and respond financially to a deliberate decision by a company to forgo $1.5 billion in annual revenue to advance public health. Stopping tobacco sales may bring the United States closer to the Healthy People 2020 goal of less than 12% smoking prevalence.5 Victor O. Kolade, MD, MS

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Potential conflicts of interest for academic medical center leaders--reply.

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