Saturday, November 10, 2018

Are the foxes watching the henhouse?

Increasingly, doctors are expected to follow published guidelines on how to evaluate and treat patients. In many cases, payment is predicated on following these guidelines and in other circumstances, payment for "quality" is geared to compliance with them. There are now literally thousands of such guidelines, often conflicting with each other.
Many professional organizations convene panels of "experts" to issue guidelines on how doctors should evaluate and treat patients. These have the aura of being the last word on the subject, and are used both to guide the practice patterns of individual physicians and often what insurance companies will pay for. It would be wonderful to believe that the panel experts were both knowledgeable and unbiased, but growing evidence says that the panel members all too often have serious conflicts of interest. Some of these are inherent to being in the specialty; if you are a diabetes expert, it is wonderful to lower the threshold at which diabetes is diagnosed and instantly have millions of more diabetics needing your care. Others are financial. Two recent studies published online on JAMA Internal Medicine (on October 29, 2018) looked at this. One showed that over half of the authors of clinical practice guidelines in the field of gastroenterology had financial ties to industry, and that many of these ties were not publicly revealed. Another looked at the authors of guidelines related to very high-cost medications. They identified 18 sets of guidelines covering the use of ten very high cost medications. Out of 160 US-based physicians, half declared receipt of payments from industry and an additional 25% HAD received such payments but not disclosed them. The process of developing practice guidelines needs a hard look and revision to be sure these are based on what is truly best and not what is simply good and also expensive. Guidelines should be developed by neutral experts, and should include patients, primary care providers and experts on statistics as well as specialist with expertise in the field. Read more about this in my new book, Prescription for Bankruptcy.

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