Many of us are suspicious of pharmaceutical companies, and rightly so: they have an increasing influence on medical practice. Even if they’re not necessarily being evil, the opportunity and temptation for mischief is definitely there.
A recent study by Ray Moynihan of Bond University and colleagues showed that the expert panels that define diseases often have ties to companies that stand to benefit from broadening their scope (Moynihan RM, Cooke GPE, Doust JA, Bero L, Hill S & Glasziou PP 2013, “Expanding disease definitions in guidelines and expert panel ties to industry: a cross-sectional study of common conditions in the United States”, PLoS Medicine, vol. 10, no. 8, e1001500, doi:10.1371/journal.pmed.1001500).
These panels put out guidelines for doctors that are meant to summarise the latest thinking on how a disease should be diagnosed and what treatment is recommended. And these are fairly common and significant conditions: the study looked at panels covering asthma, bipolar, high cholesterol, chronic obstructive pulmonary (i.e., lung) disease, depression, type 2 diabetes, hypertension, gastric reflux (GERD), myocardial infarction (heart attack), multiple sclerosis and rheumatoid arthritis.
What they found was that of 16 disease redefinitions published between 2000 and April 2013, ten of them proposed changes widening disease diagnosis, and only one narrowed a definition.
Furthermore, among the 14 panels which disclosed industry ties, 75% of their members had such connections – to a median of seven companies each. And 12 panels were actually chaired by people with industry ties.
Quite unsurprisingly – for cynics amongst us, at least – the highest proportions of ties were to companies that manufactured drugs used to treat the relevant disease.
For a closer look, let’s choose one of the most common conditions on the list: high blood pressure, otherwise known as hypertension.
The panel in question defined a new condition, “pre-hypertension”, where people who would previously have been considered to have normal blood pressure are at risk of future adverse effects.
Although the panel cited research for their decision – which we’ll come to later – eight of the 11 panel members had financial ties to companies that make hypertension drugs: companies like Bristol-Myers Squibb, Merck and Novartis.
You’d have to imagine it’s in the interest of those companies for more people to be prescribed blood pressure medication. Which isn’t good, considering those drugs have been shown not to be much help for people with mildly high blood pressure, i.e. between 140/90 and 159/99 (Diao D, Wright JM, Cundiff DK & Gueyffier F, “Pharmacotherapy for mild hypertension”, Cochrane Database of Systematic Reviews 2012, issue 8, art. no.: CD006742. DOI: 10.1002/14651858.CD006742.pub2).
Not only that, but it’s part of a growing trend towards overdiagnosis, where more and more people are considered diseased, purely due to redefining illness rather than any change to the patients themselves.
So, a pretty clear case of conflict of interest, right? Well, maybe… But when you look deeper into the actual change, the story’s slightly different.
In the report where the panel introduced pre-hypertension – defined as blood pressure between 120/80 and 139/89 – they actually recommended patients change their lifestyle to prevent heart disease – not take medication (Chobanian AV, Bakris GL, Black HR, et al. 2003, “The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report”, Journal of the American Medical Association, vol. 289, no. 19, pp. 2560-2571, doi:10.1001/jama.289.19.2560).
So they’re not necessarily getting new customers for the companies they’re tied to – in fact, if the lifestyle changes work they could be losing future customers.
And given that there are indeed studies that claim pre-hypertension triples your risk of heart attack, then improving your lifestyle probably isn’t a bad thing (Qureshi AI, M. Suri MFK, Kirmani JF, Divani AA, Mohammad Y 2005, “Is prehypertension a risk factor for cardiovascular diseases?”, Stroke: Journal of the American Heart Association, no. 36, pp. 1859-1863, doi: 10.1161/01.STR.0000177495.45580.f1).
Now, to be fair Moynihan et al’s paper didn’t actually make any judgements about whether the disease redefinitions were good or bad. And they also admit that they haven’t proven that industry ties are causing the broadening of diagnoses – in the absence of control groups, you can’t say what a non-industry panel would have concluded.
But it does show how the system works, and it raises questions about what can or should be done to avoid conflicts of interest. One of those probably is to make sure frontline doctors are independent and fully-informed of the biases, so that they can choose the best treatment for each patient.
Human nature being what it is, if there’s an opportunity for abuse of power, someone’s going to abuse it.
(This story first aired on 12 September 2013 – you can listen to the podcast.)