Wednesday, March 30, 2011
Cardiovascular Guideline Committees (Half) Rife with Conflicts of Interest
A pair of articles in the most recent Archives of Internal Medicine (subscription required) address the problem of conflict of interest (COI) among the panelists writing guidelines for the treatment of cardiovascular disease. These guidelines become more and more important as insurers pay special bonuses to docs based on how well the docs follow such guidelines (pay-for-performance). Mendelson and colleagues surveyed the landscape--specifically, the most recent 17 guidelines (as of 2008) put together jointly by the American Heart Association and the American College of Cardiology--and report that 56% of the individual members of the panels had COIs. The most common relationships were being a paid consultant or a paid member of a scientific advisory board (in other words, not merely getting research funding, which might be viewed as a more tolerable COI). Chairs of the guideline panel were more likely than mere members to have COIs. Mendelson et al's conclusion was that the glass is half full--there do in fact seem to be a substantial number of potential guideline panelists who don't have COIs, so if one tried, it should not be too hard to assemble a non-conflicted panel (meaning of course that no one is trying that hard). Dr. Steve Nissen of Cleveland Clinic is usually reliable on this topic and does not disappoint in the commentary that he contributes. He notes that the COIs reported here extend "far beyond scientific collaboration. More than half of [guideline] writers served as promotional speakers on behalf of industry, and a substantial number actually held stock in companies affected by the [guideline]." He adds: "Participants in speaker's bureaus essentially become temporary employees of industry, whose duty is the promotion of the company's products....To allow such individuals to write [guidelines] defies logic." Nissen goes on to note that this might not be quite so bad if all the guideline panelists did (as some defenders of the status quo claim) was to carefully sort out high-level scientific evidence. But according to another study, at least half of all the recommendations made by such guideline panels are based not on high-quality evidence, but rather only on "expert opinion." When something as subjective as "expert opinion" shapes that much of what the guidelines contain, then it becomes that much more important to eliminate the potential biases introduced by commercial COI. Nissen concludes, "The revelations related in the current article highlight troubling concerns that must be urgently addressed. If we fail as a profession to police our [guideline] process, the credibility of evidence-based medicine will suffer irreparable harm." Mendelson TB, Meltzer M, Campbell EG, et al. Conflicts of interest in cardiovascular clinical practice guidelines. Archives of Internal Medicine 171:577-84, March 28, 2011. Nissen SE. Can we trust cardiovascular practice guidelines? Archives of Internal Medicine 171:584-85, March 28, 2011.