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Conflicted Experts

Can conflicts of interest shape clinical guidelines?

By Abdul El-Sayed

Published August 26, 2013

Disease is business. In 2010, we spent $2.6 Trillion on healthcare in the U.S.—15% of our annual gross domestic product. That’s a lot of money to be had.

Contrary to what most of us think, for most doctors, hospitals, and drug companies, a patient’s best interest isn’t always the ultimate goal. Instead, in our for-profit health system, helping people feel better is a means to the greater end of making a buck.

The goal of helping patients usually aligns well with the goal of making money: the patients feel better and doctors, hospitals, and drug companies get paid. It’s business as usual. This for-profit medical system, though, even at its best, has troubling consequences for the way our health system works—and sometimes doesn’t work.

But none of those consequences are as dangerous as what can happen when those interests do not align. In these situations, the goal of making money conflicts with the goal of doing what’s best by people. Conflicts of interest can lead to devastating consequences for the health of patients, populations, and the health system alike.

This is particularly true when they shape the guidelines which doctors all over the world use to diagnose and treat patients every day.

Medical science is vast and often conflicting. Therefore, it’s a tall order for individual doctors, who see patients day-in and day-out, to make sense of the data themselves. Instead, they often rely on the guidelines of expert committees of prominent researchers and clinicians, convened by respected specialty boards, such as the American College of Physicians or the American Academy of Pediatrics, who come together to distill the science and weigh the evidence.

Drug companies have an incentive to hire the types of researchers and clinicians who are asked to serve on these panels as spokespeople who are often flown around the country to give lectures to clinicians about the drugs their sponsoring company is peddling.

What happens when the experts on the payroll of big pharma sit down together to make guidelines that shape how doctors diagnose and treat disease? That’s what a recent study published in the eminent medical journal PLoS Medicine asked.

The findings are worrying. The authors considered 16 expert panels convened between 2000 and 2013 to define diagnostic criteria for diverse diseases, including depression, hypertension, and high cholesterol. Fourteen of these 16 panels had members who disclosed conflicts of interest, and 12 of them were chaired by members with conflicts of interest. Unsurprisingly, in most of these panels, diagnostic boundaries were widened, increasing the number of people with potential diagnoses and therefore, the number of potential drug customers. None of the panels considered a rigorous assessment of the potential harms of treating patients at the cusp, who would be reclassified as ill per the expanded diagnostic criteria.

The study suggests that conflicts of interest may be shaping the guidelines doctors use to diagnose and treat patients everyday. And that has serious implications for individual patients, populations, and the health system overall.

With respect to individuals, artificially permissive diagnostic criteria will increase the number of people who are treated for a given disease. While this may sound at first like a good thing, it is, in fact, very dangerous. All drugs have side effects and pose the risk of interacting with other drugs. Therefore, the decision to treat any given patient carries with it a risk-benefit analysis of the potential for improvement in symptoms or outcomes weighed against the potential side effects of treatment. Because those who are most likely to be diagnosed as a result of these more permissive guidelines are those who, by definition, have the least serious disease, the potential benefits of treatment may not outweigh the potential risk of harmful side effects and interactions.

Moreover, diseases such as depression and high cholesterol are stigmatized in the medical system. In that respect, labeling patients who otherwise might not meet criteria with these diagnoses can influence the ways providers treat them as they move through the medical system.

This translates, ultimately, into a higher burden of unnecessary treatment and a concomitant increase in the incidence of treatment side effects and harmful drug interactions across the population.

The health system also suffers. At nearly one-sixth of GDP, the U.S. healthcare system is the most expensive in the world. Inflating disease definitions to create demand for pharmaceuticals simply adds to its bloated costs. In that respect, government health services like Medicare and Medicaid, which are the bedrocks of healthcare for vulnerable populations, will feel the strain of the added costs of treating disease that would not exist otherwise. In this way, these conflicts of interest drain the resources of institutions that support our society’s poor and elderly.

Unfortunately, in our for-profit health system, disease is business. And conflicts of interest are so damaging because they put that business before patient, population, and health system interests in ways that aren’t always obvious at first—but that can have very dangerous long-term consequences.

Edited by Dana March.

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The views and opinions expressed on this website are solely those of the authors and do not represent those of the Department of Epidemiology, the Mailman School of Public Health, or Columbia University.