Clinical practice guidelines sound good in theory. Written by top-notch experts, they're supposed to give doctors a recipe for diagnosing and treating specific medical conditions based upon the latest research evidence. No more needless tests and treatments; reduced medical costs; lower death rates and fewer repeat hospitalizations.
But what if the experts who write these guidelines are on the industry dole? What if they're just a tad more favorable towards a specific treatment or diagnostic procedure because they get paid to promote it at medical conferences? How good are those guidelines now? Turns out, clinical guidelines are frequently written by doctors with such conflicts of interest, especially those written for the management of heart disease, according to a study published Monday in the Archives of Internal Medicine.
The study found that out of 500 individuals involved in the development of cardiology guidelines, nearly half had such conflicts. "This raises questions about the ability of the public to trust clinical practice guidelines," says study co-author Eric Campbell, director of research at the Mongan Institute for Health Policy at Massachusetts General Hospital.
Practice guidelines like this new one for preventing heart disease in women specify when cholesterol-lowering drugs, beta blockers, and blood thinners should be prescribed. Nearly half of the folks who served on the panel that wrote these guidelines took speaker fees from drug companies and 13 of the 22 panel members served on advisory boards of drug or medical device companies.
And one-third of the writers of a different clinical guideline concerning the performance of angioplasties to open blocked arteries owned stock in the companies affected by that intervention.
"There's no reasonable explanation for why individuals who serve as part-time sales people or who hold stock in companies should be able to serve on these committees," says Campbell. He recently served on an Institute of Medicine panel that made recent recommendations for the writing of trustworthy clinical guidelines. Among them, "whenever possible, guideline development group members should not have a conflict of interest."
That's because all too often, Campbell says, there's not enough research to clearly determine what the guidelines should be, so experts rely on their own knowledge base to come to a consensus. Biases in favor of a particular treatment or diagnostic device can easily creep in to determine how a guideline should be worded.
In an editorial that accompanied the study, Cleveland Clinic cardiologist Dr. Steven Nissen complained that the root of the problem lies with the professional medical societies and associations, like the American Heart Association, that issue the guidelines and also rely heavily on industry funding.
No question these societies make good use of the funding to educate physicians as well as patients, but that could come at a cost. "The extent to which such financial ties bias the selection of [clinical practice committee] chairs and writers is unknown," Nissen wrote, "but it certainly raises appropriate concerns."
The financial ties to industry are particularly strong among cardiologists, says Campbell. He and his colleagues found in a study published last year that 93 percent of cardiologists take some money from industry and that three-quarters accept gifts from medical companies.
"Companies wouldn't engage in a relationship with physicians unless it was having an impact on bottom line," says Campbell "and that impact is selling drugs."
So what can patients do to get the best care for themselves?
"Ask your doctor for the evidence behind why he or she is recommending a particular drug, test, or treatment," says Campbell. And if you're doing well on whatever therapy you're on and your doctor wants to switch you to the latest drug on the market, make sure to understand the reason for the switch and whether there's any data -- preferably from government-funded studies -- comparing the new drug to the older one.
You can also check to see whether your doctor has any financial ties through this website run by the Massachusetts Office of Health and Human Services. Manufacturers of pharmaceuticals and medical devices are required to disclose certain payments or gifts with a value of at least $50 to anyone who prescribes, dispenses, or purchases prescription drugs or medical devices in the Commonwealth.
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