By Dr. Kate Scannell, Syndicated Columnist
First Published in Print: 04/02/2011
BY NOW, most of us know what a "GPS" is -- at least those of us who tend to get lost and require a "global positioning system" to navigate us toward our desired destination. But how many of us are familiar with the "CPGs" our doctors use to navigate our medical care?
A CPG is a "Clinical Practice Guideline," and it functions like a GPS for doctors and patients. For example, when a medical decision must be made for a diabetic patient, the doctor might consult a "CPG for diabetes" to select a course of management among several options. Depending on that course, the CPG could navigate doctors toward ordering certain tests or prescribing particular medications.
CPGs are created by a hodgepodge of private and public organizations that share some interest in the focus of the CPG. So, for example, the American Diabetes Association creates CPGs regarding diabetes management. The Academy of Ambulatory Foot and Ankle Surgery issues guidelines concerning ingrown toenails. More than 1,000 CPGs exist, spanning a vast array of medical disorders including heart disease, arthritis, thyroid problems, high blood pressure and various cancers.
Ideally, organizations volunteering to create guidelines do us a favor, because it is impossible for most doctors to keep up with the thousands of new research findings published each year in medical journals. We doctors tend to welcome CPGs that are written by groups of professionals who have expertly reviewed, analyzed, distilled, synthesized and translated complex research findings into useful clinical practice recommendations.
It's important to understand about CPGs because doctors frequently rely upon them to determine what happens to you when you're sick. Certainly, you'd want to feel confident that the CPGs your doctor references are up-to-date, free of financial bias and based upon the best available medical knowledge. If, by following a CPG's guidance with your doctor, you make a decision to begin a new medication -- incurring its costs and potential side-effects -- you'd want to know that the route you took to arrive at that decision was credible and mapped by experts with your best interests at heart.
But suppose you discover that the CPG guiding your decision had been mapped by doctors who owned financial stakes in the outcome or course of your treatment? How would you know whether to trust your decision?
Last week, the Archives of Internal Medicine published a study analyzing 17 major CPGs written by the American College of Cardiology or the American Heart Association. The CPGs included advisement about the management of heart failure, stroke, and heart attacks, as well as the use of various diagnostic or surgical interventions for cardiac conditions. Researchers discovered that more than half of the people who wrote those CPGs had private financial arrangements with companies that created the potential for self-interest or profit. Many of those CPG writers were physicians.
In fact, fully 56 percent of the 498 guideline writers were company stockowners or beneficiaries who received consulting fees, research grants or lecture payments. And the actual percentage is likely to be greater, because researchers had to rely on self-reported disclosures only.
In a case involving a CPG that advised about a procedure's use to unblock narrowed coronary arteries, one-third of the guideline writers owned stock in affected companies. In another example, three-quarters of stroke prevention guideline authors were company-paid lecturers or speakers. The researchers of the new study concluded that many of the cardiology guideline recommendations were based more on opinion "than on clinical trial data."
Overall, this new report is thoroughly disheartening. Why should the health of patients be subjected to such commercially contaminated advice? How should doctors in the clinical trenches interpret CPGs that are written under commercial influence?
Don't get me wrong -- of course it's possible for a company-paid doctor to write a CPG that is fair, unbiased and not favoring the "company he keeps." And it's also possible that companies maintain doctors on payrolls who advocate competitor companies' drugs or medical devices. Right?
The problem is that we simply cannot know when the lure of financial incentives has -- or has not -- coaxed a CPG writer down a path toward the company store and away from the best interests of patients. There is no reliable yardstick to measure operative bias.
When done well -- based on objective analysis and solid evidence -- CPGs of unquestionable integrity can help us make more logical and better health care decisions.
They can create standards of good medical care that, used as references, allow us to identify and remedy health care disparities among diverse populations of patients. With trustworthy CPGs at their disposal, doctors and patients can experience greater confidence about the legitimacy of their clinical decisions.
Regrettably, concerns about potential conflicts of interest among CPG writers are not unique to the cardiology field. They are pervasive and entrenched throughout the entire spectrum of medical and surgical subspecialties.
I am waiting for public outcry against all of this. Meanwhile, I fantasize about owning a magical GPS unit that gives directions to my profession. I reprogram its current route, away from distracting and lucrative sidelines, and I enter "patients" as the sole "destination."
––––––––––––––––––––––––––––––––––––––––––––
Kate Scannell is a Bay Area physician and syndicated columnist. She has authored "Flood Stage" and "Death of the Good Doctor."
2011 Copyright, Kate Scannell
First Published in Print: 04/02/2011
BY NOW, most of us know what a "GPS" is -- at least those of us who tend to get lost and require a "global positioning system" to navigate us toward our desired destination. But how many of us are familiar with the "CPGs" our doctors use to navigate our medical care?
A CPG is a "Clinical Practice Guideline," and it functions like a GPS for doctors and patients. For example, when a medical decision must be made for a diabetic patient, the doctor might consult a "CPG for diabetes" to select a course of management among several options. Depending on that course, the CPG could navigate doctors toward ordering certain tests or prescribing particular medications.
CPGs are created by a hodgepodge of private and public organizations that share some interest in the focus of the CPG. So, for example, the American Diabetes Association creates CPGs regarding diabetes management. The Academy of Ambulatory Foot and Ankle Surgery issues guidelines concerning ingrown toenails. More than 1,000 CPGs exist, spanning a vast array of medical disorders including heart disease, arthritis, thyroid problems, high blood pressure and various cancers.
Ideally, organizations volunteering to create guidelines do us a favor, because it is impossible for most doctors to keep up with the thousands of new research findings published each year in medical journals. We doctors tend to welcome CPGs that are written by groups of professionals who have expertly reviewed, analyzed, distilled, synthesized and translated complex research findings into useful clinical practice recommendations.
It's important to understand about CPGs because doctors frequently rely upon them to determine what happens to you when you're sick. Certainly, you'd want to feel confident that the CPGs your doctor references are up-to-date, free of financial bias and based upon the best available medical knowledge. If, by following a CPG's guidance with your doctor, you make a decision to begin a new medication -- incurring its costs and potential side-effects -- you'd want to know that the route you took to arrive at that decision was credible and mapped by experts with your best interests at heart.
But suppose you discover that the CPG guiding your decision had been mapped by doctors who owned financial stakes in the outcome or course of your treatment? How would you know whether to trust your decision?
Last week, the Archives of Internal Medicine published a study analyzing 17 major CPGs written by the American College of Cardiology or the American Heart Association. The CPGs included advisement about the management of heart failure, stroke, and heart attacks, as well as the use of various diagnostic or surgical interventions for cardiac conditions. Researchers discovered that more than half of the people who wrote those CPGs had private financial arrangements with companies that created the potential for self-interest or profit. Many of those CPG writers were physicians.
In fact, fully 56 percent of the 498 guideline writers were company stockowners or beneficiaries who received consulting fees, research grants or lecture payments. And the actual percentage is likely to be greater, because researchers had to rely on self-reported disclosures only.
In a case involving a CPG that advised about a procedure's use to unblock narrowed coronary arteries, one-third of the guideline writers owned stock in affected companies. In another example, three-quarters of stroke prevention guideline authors were company-paid lecturers or speakers. The researchers of the new study concluded that many of the cardiology guideline recommendations were based more on opinion "than on clinical trial data."
Overall, this new report is thoroughly disheartening. Why should the health of patients be subjected to such commercially contaminated advice? How should doctors in the clinical trenches interpret CPGs that are written under commercial influence?
Don't get me wrong -- of course it's possible for a company-paid doctor to write a CPG that is fair, unbiased and not favoring the "company he keeps." And it's also possible that companies maintain doctors on payrolls who advocate competitor companies' drugs or medical devices. Right?
The problem is that we simply cannot know when the lure of financial incentives has -- or has not -- coaxed a CPG writer down a path toward the company store and away from the best interests of patients. There is no reliable yardstick to measure operative bias.
When done well -- based on objective analysis and solid evidence -- CPGs of unquestionable integrity can help us make more logical and better health care decisions.
They can create standards of good medical care that, used as references, allow us to identify and remedy health care disparities among diverse populations of patients. With trustworthy CPGs at their disposal, doctors and patients can experience greater confidence about the legitimacy of their clinical decisions.
Regrettably, concerns about potential conflicts of interest among CPG writers are not unique to the cardiology field. They are pervasive and entrenched throughout the entire spectrum of medical and surgical subspecialties.
I am waiting for public outcry against all of this. Meanwhile, I fantasize about owning a magical GPS unit that gives directions to my profession. I reprogram its current route, away from distracting and lucrative sidelines, and I enter "patients" as the sole "destination."
––––––––––––––––––––––––––––––––––––––––––––
Kate Scannell is a Bay Area physician and syndicated columnist. She has authored "Flood Stage" and "Death of the Good Doctor."
2011 Copyright, Kate Scannell