Although medical professionals are concerned about bias introduced from commercial funding of continuing medical education (CME), many are not willing to pay higher fees to offset or eliminate such funding sources, according to a survey published May 9 in the Archives of Internal Medicine.

In 2006, participants (physician and non-physician healthcare practitioners) attended 12.8 million hours of accredited CME activities, representing a total income of $2.38 billion, according to the authors. Commercial support, advertising and exhibit income represented 60 percent of this total revenue. “Some have proposed measures to limit the size, scope and potential influence of commercial support for CME activities,” they wrote.

Therefore, Jeffrey A. Tabas, MD, office of the CME, department of emergency medicine at University of California, San Francisco, and colleagues sought to determine whether participants at CME activities perceive that commercial support introduces bias, whether this is affected by the amount or type of support and whether they would be willing to accept higher fees or fewer amenities to decrease the need for such funding.

The researchers delivered a structured questionnaire to 1,347 participants at a series of five live CME activities about the impact of commercial support on bias and their willingness to pay additional amounts to eliminate the need for commercial support.

The survey items targeted four main areas:

• Beliefs about commercial funding and potential for bias (10 items);
• Willingness to offset the cost of commercial support (10 items);
• Knowledge about some of the costs associated with providing a CME course (nine items);  and
• Demographic information, including years in practice and types of interaction with industry in the prior three years.

Of the 770 respondents, 88 percent believed that commercial support introduces bias, with greater amounts of support introducing greater risk of bias, the researchers reported. Only 15 percent, however, supported elimination of commercial support from CME activities, and 42 percent were willing to pay increased registration fees to decrease or eliminate commercial support.

According to Tabas and colleagues, participants who perceived bias from commercial support more frequently agreed to increase registration fees to decrease such support (two- to three-fold odds ratio).

Also, they noted that participants greatly underestimated the costs of ancillary activities, such as food, as well as the degree of support actually provided by commercial funding. In fact, almost 85 percent underestimated the cost of lunch, and 88 percent underestimated the cost of coffee at their respective site.

“Although there is little direct evidence about the degree to which commercial support of CME activities introduces bias, there is substantial indirect evidence to suggest that it plays a role in shaping both topic selection and presentation of information favorable to a company's products or unfavorable to their competitors' products,” the study authors wrote. “Even less is known about the impact of commercial support on participants' perception of bias and what they may be willing to sacrifice in order to decrease or eliminate such funding.”

Therefore, Tabas et al suggested that the disconnect between the anticipation of bias and the detection of bias by physicians at CME activities “requires further investigation.”

The researchers said their survey showed that participants at CME activities have “little understanding” of the costs involved in such an activity, and therefore may underestimate the impact of eliminating commercial support. Overall, 75 percent underestimated the amount of commercial funding for their course.

“In fact, meeting venue costs are expensive and complex,” the authors wrote. “Contracts to hold space at hotels usually involve commitments to sell an agreed number of sleeping rooms, with penalties if those numbers are not met. Food and beverage is often one of the largest costs to CME activities at hotel and meeting venues.”

The dilemma remains of how to provide quality CME either with alternate funding or at reduced cost. One suggestion, according to the authors, is to reduce costs by holding meetings and events at less expensive facilities and locations or reducing speaker honoraria. “Barring a substantial reduction in the cost of delivering CME, however, a rapid reduction or elimination of funding might be unacceptably disruptive, and some have postulated that such a change will result in the disappearance of live CME as we know it and the development of other forms of CME,” they warned.

“Given the reality that CME learners underestimate the actual costs of live CME activities, the impact of decreases or changes in funding sources needs to be further clarified, and an understanding of the perceptions of these learners and efforts to better inform these clinicians of the true costs of CME needs to be taken into account in the implementation of any policy change,” Tabas and colleagues concluded.