Peer review is supposed to help root out bias in continuing medical education content. But who's monitoring reviewers for their conflicts of interest?
CME providers have come to recognize the potential conflicts of interest that exist throughout the content development process, and they have gone beyonddisclosures, implementing methods to identify and resolve COIs in order to ensure their activities are independent of commercial influence. The Accreditation Council for CME cites peer review and the use of best available evidence as effective mechanisms for resolving COI. Although many accredited providers now have a peer review process in place, the processes can vary considerably from provider to provider.
It seems that when it comes to the peer review process, providers often neglect to adequately define and assess conflicts of interest. Some providers use the activity chairperson as the content reviewer, others require only that the reviewer not be involved in developing the draft content, and others merely stipulate that reviewers have no relationship with the commercial supporter. However, in these times of intense scrutiny, it is important that peer reviewers be held to high standards. Providers should determine minimum qualifications as well as activity-specific qualifications.
Excluding Internal Reviewers
Inherent conflicts of interest exist for peer reviewers who are employees or contractors of CME providers. A peer reviewer's objectivity can be affected by personal income, job security, organizational revenue, internal politics, and even his or her relationship with the presenter/author or activity chairperson. Therefore, it is important to differentiate internal reviews, which are useful in program management, from peer review.
This expanded definition could theoretically exclude the following persons from acting as peer reviewers: activity chairpersons/program directors, employees of the accredited provider and educational partner, members of the accredited provider's advisory board and activity planning committees, and those who hold other roles within the organization and could have relationships with the supporter.
The selection of qualified external peer reviewers provides an opportunity to bring more objectivity, expertise, and candor than may be possible from those close to the activity or to the provider's CE program.
To enhance the independence and effectiveness of peer review, we propose that an independent reviewer be defined as an individual who meets the following criteria:
meets pre-established qualifications, e.g., level of experience, knowledge, competence;
is outside of the accredited provider organization;
is not involved in the development of the content being reviewed;
has no direct connection to the author of the activity; and
has no relationship with the activity funder(s) or other commercial interests within a closely related therapeutic area.
The current list of corporate integrity agreements, the recent concerns about the National Institutes of Health and the Food and Drug Administration COI policies, and the Senate Finance Committee's criticism of CME remind us that the imposition of external standards is a real threat. Establishing our own valid and rigorous peer review standard now will avoid the appearance of impropriety, while enhancing our credibility and integrity.
Jane M. Ruppenkamp, a 18-year CME veteran, is president, CME Peer Review LLC, Greencastle, Pa., and partner, PTR Educational Consultants LLC.
Kristi E. Eidsvoog, PhD, a 13-year CME veteran , is president, EVG Consulting, Downingtown, Pa.