Wednesday, July 29, 2015

Financial conflicts of interest have no place on guideline panels

In a series of editorials in the New England Journal of Medicine earlier this year, Dr. Lisa Rosenbaum stirred controversy by suggesting that policing of pharmaceutical conflicts of interest in medicine had gone too far. These editorials and the passionate responses they elicited (especially those authored by three former NEJM editors and leaders of the Lown Institute) are worth reading in their entirety. I recently weighed in on this debate in a Medscape video commentary (the fifth in a continuing series) by discussing the narrower question of whether it is a problem if practice guidelines are developed by members with financial conflicts of interest. Below are two excerpts:

I strongly disagree with Dr Rosenbaum that preventing physicians with financial conflicts from developing guidelines or from creating continuing medical education materials will reduce their quality or usefulness. In fact, I believe the opposite to be true. Experts in medical subspecialties are not only more likely to be financially biased but intellectually biased as well. Is it any surprise that radiologists are up in arms about the US Preventive Services Task Force's conclusion that screening mammography in women in their forties should be optional or that urologists are opposed to the Task Force's recommendation against prostate-specific antigen screening in men? ... As the Institute of Medicine has affirmed, the primary qualification for membership on a trustworthy guideline panel should be expertise in evidence-based medicine. ...

The VA/DoD [cholesterol treatment] guideline suggested higher 10-year cardiovascular risk thresholds [than the ACC/AHA guideline] for recommending a statin for primary prevention (12% vs 7.5%) and for considering a statin for primary prevention (6% vs 5%). They also preferred moderate-dose to high-dose statins in most clinical situations. Why is the VA/DoD guideline more conservative about statin use? Same evidence, different panel, different conclusions. It's worth noting that none of the VA/DoD panelists had any financial conflicts of interest.