Rooting Out Conflicts of Interest from Clinical Treatment Guidelines

Although people skills are critical to good doctoring, at heart physicians are (or are supposed to be) scientists. They are obliged to remain current with the science in their field. Because the body of knowledge never stops growing, that’s a big job. And conflicts of interest make it tougher, when the writers of practice guidelines are in the pocket of Big Pharma.

Writing in the New York Times earlier this month, Dr. Jerry Avorn, professor of medicine at Harvard and author of “Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs,” has captured the difficulty of digesting the big, endless meal that turns continuing education into clinical practice.

Docs get help, he says, from medical groups that issue clinical-practice guidelines derived from experts sorting through reams of clinical research and drug studies, and publishing summaries about what treatments work best.

But their advice can be imperfect. Avorn cites recent recommendations from the American Association of Clinical Endocrinologists for diabetes treatment. It placed many drugs higher in the prescribing hierarchy than some familiar, popular and generic drugs like metformin. The organization also emphasized that established treatments like insulin and glipizide are risky.

But several of new, promoted drugs are expensive and lack the proven records of clinical effectiveness and safety that the older drugs have. It’s one thing to have new treatment choices, and another to have them because their manufacturers might have had a role in the development of the guidelines because some their authors were paid consultants of the manufacturers.

We’ve covered this conflict of interest before.

Avorn recalls practice guidelines for treating anemia in patients with kidney disease that recommended high doses of the drug erythropoietin. But such doses substantially increased the risk of heart attack, stroke and death, “with little countervailing benefit,” he writes. “Here, too, the professional society that issued the guidelines, as well as many of the doctors who formulated them, received funding from companies marketing the drug.”

Pharmaceutical companies love to flog their new, expensive drugs, never mind, says Avorn, that “there is much less muscle behind efforts to encourage the use of established, off-patent drugs, even when the weight of evidence and experience recommends them.”

And when the medical literature reports solidly conducted trials resulting in thoughtful, balanced clinical guidelines, doctors need help harvesting the crop, then sorting the wheat from the chaff.

Enter several groups – including the Institute of Medicine, the American College of Physicians and the Cochrane Collaboration, a network of experts who evaluate clinical research – that sift through medical information to synthesize and present the honest science.

Docs also get help from the Independent Drug Information Service, a nonprofit service funded by the state of Pennsylvania and the District of Columbia. It assesses medical literature absent of any product-driven bias. Then it dispatches pharmacists and nurses to doctors’ offices to guide them through the treatment recommendations the analysis yields.

It’s a front-line defense against the pharmaceutical industry, which deploys armies of sales representatives to promote their products directly to doctors. Such practices, as we’ve noted, can be rife with exploitation.

“A few large health systems,” Avorn writes, ” including Kaiser Permanente and the nation of Australia, have adopted this curator-docent approach, which has been shown to improve doctors’ clinical decision making. The programs can also control costs over time, as they counter the influence of drug companies promoting the most expensive new drugs, whether or not they’re an improvement. But to make a significant difference, many more health-care systems, both private and public, must adopt them.”

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