What If the Institute of Medicine Wrote a Report and Nobody Followed it? - the Case of the Standards for Developing Trustworthy Guidelines

<br />For over 20 years, clinical practice guidelines (CPGs) have been touted to improve health care quality and control costs.  Enormous numbers of guidelines have been developed, but with seemingly little impact on health outcomes.  While some of those leading health care organizations have predictably blamed individual practitioners for obstinately ignoring or challenging guidelines, there is increasing evidence that maybe the guidelines themselves are part of the problem.<br /><br /> <b>An Example of a Guideline that Apparently was Not Trusted</b><br /><br />One example Dr Wally Smith and I have taught in our recurring mini-course on why physicians fail to follow guidelines (and otherwise appear not to practice in accord with others' wishes) is that of the guidelines on management of depression in primary care.  Most existing guidelines urge physicians to screen patients for (presumably mild-to-moderate) depression and treat them aggressively, with emphasis on the use of the newer anti-depressants.  These guidelines, in turn, were based on numerous published randomized clinical trials that showed that these drugs were safe and efficacious.  Yet multiple studies showed that physicians failed to follow these guidelines, and various attempts to improve their adherence did little.  So for years the assumption was that physicians at best experienced practical and system barriers to follow these guidelines, and at worst were ill-informed or irrational.  <br /><br /><br />However, information that came out gradually during the early part of the 21st century suggested that perhaps the problem was within the guidelines, not the health care professionals.  First, documents produced during New York Attorney General Eliot Spitzer's lawsuit against GlaxoSmithKline about the marketing of one of these drugs (Paxil, paroxetine) suggested that the company had suppressed clinical trial data that reflected poorly on the drug (See Kondro W.  Drug company experts advised staff to withold data about SSRI use in children.  Can Med Assoc J 2004; 170: 783.  Link <a href="http://www.cmaj.ca/content/170/5/783.full">here</a>.)    These suspicions were later fleshed out  by consideration of documents further disclosed in litigation (e.g., see <a href="http://hcrenewal.blogspot.com/2012/08/continuing-dissection-of-infamous-study.html">this post</a> and its links).  Then several studies, most particularly that by Erick Turner and colleagues, showed that numerous trials of new anti-depressants had been suppressed, that is, never published (Turner et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 2008; 358:252-260.  Link <a href="http://www.nejm.org/doi/full/10.1056/NEJMsa065779">here</a>).  When the results of these trials were added to those that were published, the efficacy of anti-depressants was no longer so clear.  So maybe the guidelines that physicians did not follow were not trustworthy, and should not have been followed in the first place.<br /><br /><b>Would IOM Standards to Improve Guideline Trustworthiness Help?</b><br /><br />So in 2011, the prestigious Institute of Medicine released a report on the development of  better standards to produce more trustworthy guidelines (Clinical Practice Guidelines We Can Trust.  Link <a href="http://www.iom.edu/Reports/2011/Clinical-Practice-Guidelines-We-Can-Trust.aspx">here</a>.)  We posted about that report <a href="http://hcrenewal.blogspot.com/2011/03/institute-of-medicines-release-reports.html">here</a>, but noted that it was receiving little other attention, an example of the anechoic effect.  <br /><br />A few weeks ago, an article appeared documenting a study meant to assess the the trustworthiness of clinical practice guidelines published soon after the IOM report.  Its title telegraphs the results. ( Kung J, Miller RR, Mackowiak PA. Failure of clinical practice guidelines to meet Institute of Medicine standards: two more decades of little, if any progress.  Arch Intern Med 2012.  Link <a href="http://archinte.jamanetwork.com/article.aspx?articleid=1384245">here</a>.)<br /><br /><b>Methods and Results</b><br /><br />The investigators selected a random sample of 114 individual guidelines available during June, 2011 stratified by 26 clinical topics. The versions of the guidelines used were those archived in the National Guideline Clearinghouse (NGC) maintained by the Agency for Healthcare Research and Quality (AHRQ).<br /><br /><br />The goal of the study was to "examine adherence to the IOM standards" by guidelines published after the standards were published.  Actually, the study only assessed adherence to 18 of the 25 standards espoused by the IOM (because the remaining seven were "too vague and subjective to be analyzed.")<br /><br />Furthermore, the criteria used to determine if a specific guideline met each of the three items above were rather lax:<br /><br /><br /><blockquote class="tr_bq">In evaluating each guideline summary, care was taken to be as liberal as possible in considering that a standard was met when the individual guideline summary provided any information pertaining to that particular standard.</blockquote><br />Nevertheless, using these lax standards to only evaluate adherence to 18/25 guidelines, the authors found that "the overall median number of IOM standards satisfied (out of 18) was 8 (44.4%) ....  Fewer than half of the guidelines surveyed met more than 50% of the IOM standards."<br /><br />An examination of the details of the study's methods reveals things are even worse than that.<br /><br /><b>Analyzing the Study's Methods to Find that Things Are Worse Than They Seem</b><br /><br />Review of the study's methods show that they provided a very optimistic view of adherence to the IOM standards.  As noted above, the study did not look for adherence to all of the IOM standards.  Moreover, those they did consider were simplified and made less rigorous.  For example, Standard 2 from the IOM on management of conflict of interest (COI) was:<br /><br /><blockquote class="tr_bq">  STANDARD 2<br />Management of conflict of interest (COI) <br /><br />2.1 <br />Prior to selection of the Guideline Development Group (GDG), individuals being considered for membership should declare all interests and activities potentially resulting in COI with development group activity, by written disclosure to those convening the GDG.<br />- Disclosure should reflect all current and planned commercial (including services from which a clinician derives a substantial proportion of income), non-commercial, intellectual, institutional, and patient/public activities pertinent to the potential scope of the CPG.<br /><br />2.2 <br />Disclosure of COIs within GDG<br />- All COI of each GDG member should be reported and discussed by the prospective development group prior to the onset of their work.<br />- Each panel member should explain how their • COI could influence the CPG development process or specific recommendations.<br /><br />2.3 <br />Divestment<br />- Members of the GDG should divest themselves of financial investments they or their family members have in, and not participate in marketing activities or advisory boards of, entities whose interests could be affected by CPG recommendations. <br /><br />2.4 <br />Exclusions<br />- Whenever possible GDG members should not have COI.<br />- In some circumstances, a GDG may not be able to perform its work without members who have COIs, such as relevant clinical specialists who receive a substantial portion of their incomes from services pertinent to the CPG.<br />- Members with COIs should represent not more than a minority of the GDG.<br />- The chair or co-chairs should not be a person(s) with COI.<br />- Funders should have no role in CPG development.</blockquote><br />However, the study boiled all this down to three items:<br />-  COIs stated<br />-  Chair has COI<br />-  Co-chairperson has COI<br /><br />Thus the study did not address standards requiring full and complete disclosure (not just some disclosure) of all COIs; consideration of how the COIs might influence the particular guideline; divestment of specific types of conflicts of interest, that is, financial investments, and cessation of participation in marketing activities or advisor boards; minimization of conflicts of all members of the committee; and barring of participation of funders in guideline development.<br /><br />Even so, the guidelines assessed did a very poor job upholding even these few liberalized standards regarding conflicts of interest.  Of the guidelines assessed, less than half, 46.8% provided ANY disclosure of conflicts of interest.  Those written by sub-specialty societies were particularly opaque in this regard.  Less than one-third, 29.3%, provided any disclosure.  Thus the majority of guidelines assessed were not at all transparent about conflicts of interest affecting the guideline development process. <br /><br />Furthermore, of the 46.8% of all the guidelines which made any disclosures of conflicts of interest, 71.4% admitted their chair people HAD a conflict of interest.  Thus, only (0.468 * [1 - .714]) = 13.3% provided assurance that they fulfilled the single requirement (from standard 2.4 above) that the chair person did not have a COI.  For the guidelines written by sub-specialty societies, by a similar calculation, only 12.2% provided an assurance that the chair had no COI.  (The proportions providing assurance that the co-chair people had no COI were even lower.)  Thus the vast majority of guidelines did not clearly follow two straight-forward standards for minimizing the effects of conflict of interest, that the guideline committee chair and co-chair should not have any relevant conflicts.  <br /><br />Given the miserable results concerning even minimal adherence to some of the IOM report's conflict of interest standards, it is likely that almost no published guidelines from 2011 came close to fulfilling the full set of IOM standards.  Despite the best efforts of the IOM, it appears that guideline developers have not progressed at all towards providing trustworthy guidelines.  <br /><br /><b>Summary</b><br /><br />An <a href="http://archinte.jamanetwork.com/article.aspx?articleid=1384244">editorial</a> (Shaneyfelt T. In guidelines we cannot trust.  Arch Intern Med 2012) accompanying the article by Kung and colleagues summarized its results thus:<br /><br /><blockquote class="tr_bq">The same problems that have plagued guideline development continue to plague guideline development; namely, their variable and opaque development methods, their often conflicted and limited panel composition, and their lack of significant external review by stakeholders throughout the development process.   As a result,<i> the trustworthiness of guidelines is limited.</i></blockquote><br />While guidelines may have seemed to be a promising method to improve health care in the early 1990s, they have failed to live up to that promise.  Shaneyfelt was not optimistic they would improve in the future:<br /><br /><blockquote class="tr_bq">I am not optimistic that much will improve.  No one seems interested in curtailing the out-of-control guideline industry.</blockquote><br />On the other hand, in my humble opinion, it is not that on one is interested in better guidelines.  It would clearly be in the best interests of patients and the public, and of health care professionals who care about the quality of their practice and the outcomes of their patients to curtail that industry.  The issue is why patients', the public's, and professional's interests were ignored.<br /><br />Neither Shaneyfelt nor Kung et al discussed why there has been so little attention to patients' and the public's health, and to health care professionalism in all this.  For a quick answer, we do not have to look far on <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a>.  <br /><br /><br />In fact, the IOM report on guideline development from 2011 was a serious challenge to the powers that be in health care.  In particular, it challenged the cozy relationships that had grown up among the organizations that undertook guideline development and the health care professionals on guideline panels on one hand and organizations that stand to gain were specific guidelines to favor their products, services, and agendas on the other.  The standards mandated transparency and honesty about conflicts of interest affecting guideline committees and the organizations which assembled them, and if upheld would have greatly reduced these relationships.<br /><br />Now it turns out that the guideline standards have been honored mainly in the breach.  Of course, these standards, while increasing trustworthiness, would have cost a lot of medical societies considerable commercial funding, and would have cost a lot of health care professionals on guideline panels considerable personal wealth.  These standards would probably also have cost a lot of companies whose products and services were addressed by guidelines to lose revenue.  So it is not surprising that the IOM standards were ignored.  Their implementation would have cost too many people who are financially benefiting from the status quo too much money.  And these people, that is, leaders of professional societies dependent on commercial outside funding, health care professionals and academic used to financial support from commercial interests, and health care corporations are good at making sure their interests are not ignored, even if their interests conflict with those of patients, the public, and well-intentioned health care professionals.   <br /><br />So, the flouting of the well reasoned IOM guideline standards adds one more reason for patients and the general public to distrust modern health care and all those who "deliver" it, even to distrust well-intentioned health care professionals who have not been able to distinguish themselves from their colleagues who are too happy to help commercial interests while taking commercial money.  If health care professionals want to regain the public's trust, they could do worse than publicly declaring their intention to show that their practice in the future will be guided by trustworthy guidelines based on clinical research evidence and knowledge of biomedical science, drawn up by health care professionals independent of commercial interests.

What If the Institute of Medicine Wrote a Report and Nobody Followed it? - the Case of the Standards for Developing Trustworthy Guidelines

For over 20 years, clinical practice guidelines (CPGs) have been touted to improve health care quality and control costs.  Enormous numbers of guidelines have been developed, but with seemingly little…

Đọc thêm »

BLOGSCAN - Television Advertising Revenue and the Anechoic Effect

<span style="color: #38761d;">We have often discussed the </span><a href="http://hcrenewal.blogspot.com/search/label/anechoic%20effect"><span style="color: #38761d;">anechoic effect</span></a><span style="color: #38761d;">, how cases involving or discussions of the topics we address on </span><a href="http://hcrenewal.blogspot.com/"><span style="color: #38761d;">Health Care Renewal</span></a><span style="color: #38761d;">, the concentration and abuse of power in health care, fail to produce any responses, or echoes.  Two recent blog posts discussed one way in whicht the anechoic effect might be generated.</span><br /><br /><span style="color: #38761d;">A </span><a href="http://currentmedicine.tv/2012/specialties/psychiatry/youre-telling-me-this-now-why-the-news-is-suddenly-critical-of-statins-and-antidepressants"><span style="color: #38761d;">post</span></a><span style="color: #38761d;"> by Dr Steven Greer on CurrentMedicine.TV, </span><a href="http://alison-bass.com/blog/2012/02/why-60-minutes-suddenly-discovered-the-placebo-effect-in-treating-depression"><span style="color: #38761d;">enlarged upon</span></a><span style="color: #38761d;"> by Alison Bass on the Alison Bass blog, discussed a segment on 60 Minutes yesterday that dealt with the evidence that anti-depressant drugs may not be efficacious for mild to moderate depression.  Since this evidence is about four years old, the question is why it has only made it to the main-stream media now?  Both Dr Greer and Ms Bass think it may be because the patents on most of the newer, mainly selective serotonin reuptake inhibitor (SSRI) type anti-depressants have run out.  Therefore, their manufacturers may no longer be interested in using the clout they derive from paying millions for television advertising to keep programs critical of these drugs off the air.  The implication is that large health care organizations may often use threats to withdraw advertising to forestall criticisms of their products or their agendas in the media, hence increasing the anechoic effect.</span><br /><br /><span style="color: #38761d;">ADDENDUM (27 February, 2012) See also <a href="http://1boringoldman.com/index.php/2012/02/24/the-neurotic-covenants">comments</a> on the 1BoringOldMan blog.</span> 

BLOGSCAN - Television Advertising Revenue and the Anechoic Effect

We have often discussed the anechoic effect, how cases involving or discussions of the topics we address on Health Care Renewal, the concentration and abuse of power in health care, fail to produce an…

Đọc thêm »

Quintiles to More Heavily Directly Invest in the Drugs Which it Evaluates - But Not to Worry, Says an Expert?

The Associated Press just <a href="http://www.google.com/hostednews/ap/article/ALeqM5jbIAnadjVl8lbQLqzQgrd0T3mPzwD9DSRKEO0">reported </a>on the latest trend in commercially sponsored clinical research, direct investment by contract research organizations (CROs) in the development of specific drugs by particular pharmaceutical or biotechnology companies. Here is the background in the article:<br /><blockquote>Pharmaceutical companies previously did all their own research and testing and submitted the results to the Food and Drug Administration for approval to put a medication on the market.<br /><br />Since the 1990s or so, Big Pharma has farmed out more and more of that testing to companies like Quintiles Transnational Corp., which grew quickly to meet the demand.</blockquote>Now Quintiles is branching out...<br /><blockquote>Now Durham, N.C.-based Quintiles is the world's biggest contract research organization, and more than ever,<em> it's using its deep pockets to entwine itself with the pharmaceutical companies, <strong>fronting them cash and services for a piece of the profits once a drug is approved</strong></em><strong>.</strong><br /><br />Quintiles, which was created in 1982, upped the ante last month, saying <em>it wants to invest even more in potential drugs</em> as pharmaceutical companies grapple with the down economy. Quintiles is hoping its new investments will produce enormous payoffs in the future,.... <br /><br />Quintiles' decision to become more aggressive in taking investment risks comes at a time it's betting drug makers can use the resources it can offer, both cash and services.<br /><br />'They're both currency for managing risk and having skin in the game,' said Ron Wooten, a Quintiles executive vice president who heads the company's capital investment group.<br /><br /><em>Controversy over creating the drug investment unit in 2000</em> was key in pushing Quintiles founder Dennis Gilling and several private-equity firms to buy out shareholders for $1.75 billion and take the company private again in 2003. Wall Street analysts complained they couldn't estimate what the drug investments were worth, prompting Gilling and others to decide the company's stock was undervalued.<br /><br />The private company no longer publishes its profits. It claims revenues of about $3 billion a year. That's also about what Quintiles has invested in other drug companies.</blockquote>Furthermore,<br /><br /><blockquote>Quintiles appears to be uniquely positioned to both invest in and test potential medications. <em>None of the half-dozen major shareholder-owned contract research organizations will have a drug-investment division after Wilmington, N.C.-based Pharmaceutical Product Development Inc. spins off its unit in a few months</em>, Coldwell said.<br /><br />The payoffs for the risk of developing a drug can be huge.<br /><br /><em>In 2002, Quintiles took a chance on Eli Lilly and Co.'s antidepressant Cymbalta. Quintiles said it invested $125 million in cash, then spent another $400 million on a sales force of more than 550 after the product launch. Cymbalta is now Lilly's second-biggest drug. Quintiles said it's brought in more than $700 million so far for a stream of royalties lasting to 2012.</em><br /><br />Japan's Eisai Co. is hoping Quintiles' money and experience helps it double the number of potential treatments it can put through testing simultaneously</blockquote><br />The article raised a concern that "the buffer between drug makers and testers are again blurred."<br /><br />But not to worry.... Here is the response from Quintiles,<br /><blockquote>Wooten, the Quintiles executive, <em>doesn't see his company's increased interest in bringing drugs to the market affecting its testing objectivity. Instead Quintiles is the outsider turning a hard eye on which pharmaceuticals will become profitable</em>.<br /><br />'It allows you to really get to the essence of the data that you're looking at instead of what you hope it says,' he said. There isn't 'the natural bias that you would have with your own babies.'</blockquote><br />Furthermore, the AP reporter got reassurances from a noted academic expert in the area,<br /><blockquote><em>The FDA preserves the integrity of testing in a landscape already pockmarked with potential conflicts of interest that include company-sponsored academic research and investigators testing drugs while owning shares in companies that own the drug, said <strong>Kenneth Getz</strong>, a senior fellow at Tufts University's Center for the Study of Drug Development</em>.<br /><br />The FDA's view is that any company with a financial stake in a potential drug will face similar scrutiny from the agency.<br /><br />'It's assumed,' FDA spokeswoman Karen Riley wrote in an e-mail, 'that drug/device/biologic companies who sponsor trials of pending products have a conflict because they will gain if the product is approved.'<br /><br />Besides, <em>pharmaceutical companies have navigated the tricky territory that comes with testing, Getz said. So have the companies like Quintiles that have taken on the outsourced work, he said.</em><br /><br />'These potential conflicts of interest are ever-present, and <em>the real question is how do companies manage these potential conflicts effectively</em>,' he said. 'These are massive, massive companies that have thousands of staff that are not generally aware of a conflict of interest at a corporate level. They are paid to do a quality job that meets internal and regulatory guidelines or they are not going to keep their jobs.'</blockquote><br />Here on <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a>, we have discussed how the <a href="http://hcrenewal.blogspot.com/search/label/conflicts%20of%20interest">conflicts of interest</a> that are now pervasive in health care can adversely affect clinical care, teaching, and research.  We have looked at how clinical research sponsors, who have a vested interest in having the results favor the products and services they sell, may <a href="http://hcrenewal.blogspot.com/search/label/manipulating%20clinical%20research">manipulate</a> the design, implementation, analysis, and dissemination of research, and when all else fails, <a href="http://hcrenewal.blogspot.com/search/label/suppression%20of%20medical%20research">suppress</a> unfavorable results.  We have also looked at problems with the ethics and quality of research done by <a href="http://hcrenewal.blogspot.com/search/label/contract%20research%20organizations">contract research organizations</a>, who are, after all, paid by companies again with vested interests in selling particular products or services.<br /><br />Given all that, one may argue that having contract research organizations invest in particular drugs or devices which they are also evaluating through clinical research may not make things much worse.  However, at the least, it seems to me that it further obfuscates conflicts of interest that may lead to biased research results, dishonoring the patients who volunteered for the trials, and biasing the information on which patients and physicians make decisions.<br /><br />Finally, I should note how Quintiles new investments in specific drugs was defended in the article.  The article quoted Quintiles executive vice president Ron Wooten suggesting that Quintiles might be able to be objective in making the original decision to invest in a drug. He conveniently did not address what might happen after the investment was made, when Quintiles was performing, analyzing, and reporting clinical research on a drug or device in which it had invested.<br /><br />The article also quoted Kenneth Getz, the Senior Fellow at Tufts, who seemed unconcerned about the issue.  What the article did not mention is that the Tufts Center for the Study of Drug Development, at which Mr Getz is based, <br /><blockquote><em>receives unrestricted grants from pharmaceutical and biotechnology firms</em>, as well as companies that provide related services to the research-based industry (e.g., contract research, consulting, and technology firms). <em>These grants represent approximately 40% of Tufts CSDD’s operating expenses. </em></blockquote>per the Center's <a href="http://csdd.tufts.edu/about/financial_disclosure">web-site</a>. Another <a href="http://70.42.48.93/printpage.asp?ref=http://70.42.48.93%2FAbout%2FResearchStaff.asp">page on the web-site</a> lists Mr Getz's qualifications, <br /><blockquote>Kenneth A. Getz is a senior research fellow at the Tufts CSDD. Considered an expert on the investigative site and CRO markets, R& D management, ECT solutions adoption and clinical research volunteerism,....<br /><br />Mr. Getz is the <em>founder and chairman of CISCRP</em> ....<br /><br />He holds an MBA from the J.L. Kellogg Graduate School of Management at Northwestern University and a bachelor's degree, Phi Beta Kappa, from Brandeis University. <em>Mr. Getz worked for over seven years in management consulting, where he assisted biopharmaceutical companies in planning and implementing drug development strategies. He is also the founder and former CEO of CenterWatch.</em></blockquote><br />Note that Mr Getz seems to have no training in biomedical science, medicine, or health care.  Furthermore, CISCRP (the Center for Information and Study on Clinical Research Participation), has an advisory board (see their web-site <a href="http://www.ciscrp.org/patient/who.html">here</a>) that includes representatives of pharmaceutical companies (Vertex Pharmaceuticals, Biogen Idec, and Roche), and contract research organizations, (PPD Inc, and particularly, in this case, <em><strong>Quintiles</strong></em>). The vast <a href="http://www.ciscrp.org/patient/supporters.html">list</a> of the Center's "supporters" include a catalog of drug and biotechnology companies (including Abbott Vascular, Amgen, AstraZeneca, Biogen Idec, Daiichi Sankyo Pharmaceutical Development, <em><strong>Eli Lilly</strong></em>, Forest Laboratories, Genentech, Genzyme, GlaxoSmithKline, Janssen, Johnson and Johnson, Merck, Novo Nordisk, Novartis, Ortho-McNeil, Pfizer, Roche, Sankyo, Sanofi-Aventis, Serono, Shire, Takeda, and Wyeth), and contract research organizations, (including Covance, Parexel, PPDI, and notably again, <em><strong>Quintiles</strong></em>.)<br /><br />So the other lesson from this bit of news is how the information the public, health care professionals, and policy makers  receive about health care policy is frequently shaped by people with horses in the race, but that such influences are rarely disclosed.  This article included an interview with a single apparently academic expert who provided reassurance that the conflicts of interest discussed in the article were not really so worrisome.  This expert, however, failed to disclose his own extensive, albeit somewhat indirect ties to a variety of corporations that might benefit from the conflicts discussed as the main topic of the article, including corporations that were directly involved in them (Quintiles and Eli Lilly).  Maybe because the reporter thought that the expert was unbiased, there was no attempt to find a contrasting opinion.<br /><br />So I say again, again, again, health care professionals, policy  makers, and people in general need to be extremely skeptical of most of the apparently unbiased pronouncements made about medical and health care policy issues in the media.  It would be a small step toward a more transparent discussion if those who expressed opinions would also fully disclose in detail their relevant conflicts of interest.

Quintiles to More Heavily Directly Invest in the Drugs Which it Evaluates - But Not to Worry, Says an Expert?

The Associated Press just reported on the latest trend in commercially sponsored clinical research, direct investment by contract research organizations (CROs) in the development of specific drugs by …

Đọc thêm »

The Lexapro Marketing Plan Was Meant to Promote Marketing (Surprise?)

Last week, Gardiner Harris <a href="http://www.nytimes.com/2009/09/02/business/02drug.html">writing</a> for the NY Times noted that the US Senate Special Committee on Aging had made public part of Forest Laboratories' Fiscal Year 2004 Marketing Plan for the drug Lexapro (escitalopram oxalate), an anti-depressant. The document is available <a href="http://www.nytimes.com/packages/pdf/politics/20090831MEDICARE/20090831_MEDICARE.pdf">here</a>. <br /><br />Review of this plan revealed the marketing department's various activities, including activities that others might have believed were educational, scientific, or had some other high minded purpose.<br /><br /><strong>Continuing Medical Education</strong><br /><br />Overall, one "<em>promotional objective</em>" was to "Maintain SRI category leadership in <em>total number of medical education events (including CME symposia, speaker promotion, teleconferences, and peer selling programs)</em>"<br /><br />One "critical issue" was to "<em>increase Med Ed efforts</em>: more sponsorships of CME, increased level of speaker programs, maintain level of teleconferences and peer selling."<br /><br />Under "Marketing Tactics" was a long section on "Continuing Medical Education." It covered various venues for CME such as internet/electronic CME, "sponsoring symposia at major meetings," "regional CME symposia" which would "serve a number of medical specialties," "sponsorhips of scientific sessions," etc<br /><br /><strong>Production of Scholarly Articles</strong><br /><br />The "Publications" section of "Marketing Tactics" noted "publications will be geared toward psychiatrists, PCPs, .... Articles will appear in several formats, including original reports, review articles, and journal supplements." <br /><br /><strong>Thought Leaders and Consultants</strong><br /><br />Under the "Continuing Medical Education" section of "Marketing Tactics," and then in the "Advisor Relations" section, there were numerous references to what "thought leaders" would do, including<br />- "present new data" at "symposia at major meetings"<br />- act "as advisors to Lexapro in order to obtain critical feedback and recommendations <em>on educational and promotional strategies and tactics</em>."<br />- sit on the "Lexapro Exectuive Advisory Board" to "keep our advisors apprised of the <em>commercial development</em> ... of escitalpram."<br />- sit on the "Primary Care Advisory Board" to "obtain critical feedback and recommendations on <em>educational and promotional strategies and tactics</em>...."<br /><br /><strong>Role of Medical Centers</strong><br /><br />Under the CME section of "Marketing Tactics," we see that "academic health centers" would help develop "regional CME symposia."<br /><br />Under the "Sponsorship" section are plans to fund the "Professional Relations Group in their mission of <em>establishing mutually beneficial long-term relationships with appropriate professionals and associations</em>." Specific plans included funding the Department of Psychiatry and Behavioral Sciences at Emory<br /><br /><strong>Medical Societies</strong><br /><br />The "Sponsorship section" also noted that these relationships "will also provide the basis for <em>advocacy development and issues management</em>, and will establish <em>an appropriate environment for commercial and policy activities</em>."<br /><br />Under the CME section of "Marketing Tactics, we see that "medical associations and professional societies" would help develop "regional CME symposia" Also in this section is the note that "smaller, more prestigious societis do not accept industry-sponsored symposia." So instead, "sponsorship of a study groups or plenary sessions is recommended. Marketing will work with the professional relations group regarding potential opportunities."<br /><br />Appendix VII, "Professional Associations of Priority" noted<em> funding provided for guideline development</em> by a "collaboration between APA, AAFP and ACP" for "chronic depression in primary care practice;" by AAGP for guidelines for late-life depression; multiple guidelines developed by AMDA;<br /><br />The appendix also noted that Forest supports ACNP "annual programming, and is a founding sponsor of it's newly created International College of Geriatric Pscyhopharmacology (ICGP)," is a "Corporate President's Circle Sponsor of AAFP," became a "corporate sponsor of ACP in FY03," became "a Corporate Sponsor of AMDA for the last few years," <br /><br />Also, it noted that Forest has "expanded its involvement" with APA for "lobbying of State Health Departments...."<br /><br /><strong>Disease Advocacy Organizations</strong><br /><br />Also in Appendix VII, Forest was identified as a "Corporate Sponsor of NAMI," a "major Corporate Sponsor of NMHA," and a "major Corporate Sponsor of DBSA."<br /><br /><strong>Summary</strong><br /><br />We have often heard from pharmaceutical, biotechnology, device and other health care corporations that they are only involved in education to disseminate accurate information for the good of society. We have often heard from physicians and academics who consult for such corporations that their advice is sought about clinical, scientific, and technical issues. We often hear from academic medical institutions, medical associations and disease advocacy groups that the money they get from such corporations does not influence the content of their educational and scientific work.<br /><br />Yet here we see, in considerable detail, that in the case of one drug company's promotional efforts for one drug,<br />- The marketing plan from the marketing department paid for medical education as a "promotional objective," that is, to market, not to educate.<br />- Thought leaders and consultants were again paid by marketing to market, and sometimes to provide opinions about "promotional strategies" and "commercial development."<br />- Medical associations are funded by marketing "for commercial and policy activities."<br /><br />This suggests that health care corporations develop financial relationships with physicians, academics, academic institutions, medical and professional associations, and disease advocacy groups to support marketing first. <br /><br />This allows the corporations to advance marketing disguised as education, research, and other high-minded and apparently selfless activities by professionals, not-for-profit organizations, and dedicated inviduals. Such marketing, of course, is DECEPTIVE and DISHONEST. It also is in conflict with the professionals' ideals, and the missions of the medical and professional assocations and disease advocacy groups. <br /><br />The physicians, other health care professionals, and not-for-profit organizational leaders involved may rationalize these activities as consistent with their mission and professionalism, but such rationalizations are at best self-delusion.<br /><br />No one knows how representative the Lexapro marketing plans are of the marketing of other drugs, devices and health care services. The only way to find out would be to force many other corporations' marketing plans into public view. The Lexapro documents suggest that society would benefit if many more marketing plans were made public, but that such publication might generate a wave of revulsion about how deceptive marketing of health care goods and services has become, and the extent that health care professionals have betrayed their professional ideals, and academic medical institutions, professional and medical societies, and patient advocacy groups have betrayed their missions.<br /><br />I submit that we will not truly reform health care without making the marketing of health care goods and services honest, getting health care professionals to give up their financial relationships with health care corporations to reclaim their professionalism, and getting academic medical institutions, professional and medical societies, and patient advocacy groups to give up their financial relationships with health care corporations to reclaim their missions.<br /><br />See additional comments on how the marketing plan was meant to promote CME <a href="http://carlatpsychiatry.blogspot.com/2009/09/forests-promotional-objective-use-cme.html">by Dr Daniel Carlat</a> on the Carlat Psychiatry Blog.

The Lexapro Marketing Plan Was Meant to Promote Marketing (Surprise?)

Last week, Gardiner Harris writing for the NY Times noted that the US Senate Special Committee on Aging had made public part of Forest Laboratories' Fiscal Year 2004 Marketing Plan for the drug Lexapr…

Đọc thêm »

High Costs and Poor Outcomes - A Lesson About the Suppression of Research

Last week, blogger Alison Bass was one of the few to<a href="http://alison-bass.blogspot.com/2009/08/study-confirms-that-antidepressants.html"> comment </a>on a new article on the risks of antidepressant medications published electronically last week by the British Medical Journal.[1] The article adds to the clinical evidence about these specific drugs. However, it also should remind us about why our health care costs seem to continue to inflate disproportionate to any improvements in health care outcomes.<br /><br /><strong>Background - Why Don't Doctors Diagnose and Treat Depression According to the Evidence?</strong><br /><br />Here is the background. Since the early 1990s, based on numerous published clinical trials that showed that the newer (mainly SSRI, that is, selective serotonin reuptake inhibitor) antidepressants seemed to be quite safe and effective, authoritative guidelines have urged physicians to screen patients for depression, and have a low threshold for beginning treatment, particularly with these then new drugs. (For example, see the 1993 AHCPR guidelines,[2] and the Ambulatory Care Quality Alliance Recommended Starter Set[3].) Such guidelines targeted primary care physicians as well as psychiatrists. As a primary care physician, I often felt guilty that I didn't screen all patients, including those who did not outwardly appear depressed, for depression, and was reluctant to be the primary prescriber of antidepressants for depressed patients. I was not alone. There was evidence that many primary care physicians failed to follow these apparently evidence-based guidelines.<br /><br /><strong>Suspicions that SSRIs Were Not as Effective or Safe as Thought</strong><br /><br />However, in 2004, internal documents from one drug company (Glaxo Smith Kline), published by the Canadian Medical Association Journal, suggested that the company had suppressed a study which failed to show its SSRI was effective for adolescent patients.[4] Also, then New York state attorney general Elliot Spitzer sued the company alleging it had suppressed such data.[5] Considerable anecdotal information thereafter came to light suggesting that drug companies may have suppressed data from clinical research (that is, studies done on patients, not in the laboratory) which tended to show the drugs were less effective, or more dangerous than previously thought. Many began to suspect that the drugs increased the risk of suicidal thoughts or behavior, even though one would think that if they were effective in treating depression, they should decrease such risks.<br /><br /><strong>How Does Uncovering Suppressed Trials Change the Evidence About the Benefits and Harms of SSRIs?</strong><br /><br />Then, an analysis of trials of SSRIs given to adolescent patients, which included unpublished as well as published trials, did show they increased the risk of suicide.[6] But what about adult patients?<br /><br />In 2008, Erick Turner and colleagues published a meta-analysis that included numerous trials of SSRIs and other antidepressants given to adult patients that had never been published, but whose results had been submitted to the US Food and Drug Administration (FDA).[7] When those trials were included in the analysis, the drugs seemed less effective than was previously believed.<br /><br />The new meta-analyis by Stone et al[1] suggested how adding evidence from the suppressed trials improves our knowledge about the possible harms of these drugs. Stone et al specifically addressed whether the drugs increased the risk of suicidal thoughts or actions for adult patients. It was based on data from 372 trials that included 99,231 patients. "Most of the studies were unpublished; those that had been published in some form seldom contained information concerning suicidality in the publication." Its main result was that SSRI drugs approximately doubled the risk of suicidal behavior for patients less than 25 years old, but decreased the risk for older patients.<br /><br /><strong>Suppressing Trials Distorted the Evidence-Base</strong><br /><br />Thus, the combined results of several meta-analyses suggests that SSRIs are neither as safe nor as effective for adult patients as they were previously touted to be. The drugs used to appear to be more safe and effective because the drug companies that sponsored (paid for) clinical trials of their own products suppressed the publication of studies whose results did not show their products in a favorable light. The guidelines once thought to be so authoritative are probably much to enthusiastic about the use of drugs to treat depression. It may be that those physicians who resisted pressure from these guidelines and other efforts by would-be quality improvers to diagnose more depressed patients and treat them with SSRIs weren't so dumb.<br /><br /><strong>Health Policy Implications</strong><br /><br />The recently published meta-analysis of the risk of suicidal ideation or behavior due to SSRIs for adult patients[1] adds not just to the clinical evidence about the treatment of depression, but to the evidence that suppression of research by those with vested interests in its results may not be rare. There is no reason to think that suppression of research about other medical interventions used for other clinical problems does not occur just as often.<br /><br />This underscores why we as a society should not have handed over control of how new drugs and devices are evaluated to the companies that stand to profit by selling them. The apparent benefits and safety of most drugs and devices brought to the market in recent years may have been exaggerated by the ability of the corporations who sponsored the research to suppress those studies that were least favorable to their products. Thus, it is very likely that doctors have over prescribed newer (and more expensive) drugs and devices based on erroneous beliefs about their safety and effectiveness, beliefs supported by an evidence base which was distorted by suppression of studies whose results did not show the results their commercial sponsors wanted to see. Furthermore, we have likely collectively paid too much for these drugs and devices based on these same erroneous beliefs. Thus, the distortion of the clinical evidence base caused by putting the makers of medical products in charge of their evaluation has likely led to increased costs and worse outcomes for patients.<br /><br />Health care reformers serious about wanting to improve patient outcomes and reduce costs ought to be at the forefront of a movement to make clinical research more honest. All clinical trials completed and submitted to government regulators ought to be published in some form, so that the data they contain is available to guide clinical decisions. Going forward, all studies should be published in some form in a timely manner to prevent future research suppression. There ought to be better regulation of research sponsored, and de facto run by companies who have vested interests in the results being favorable to their products. It would not be unreasonable to prevent companies with such vested interests from running or otherwise directly influencing clinical research meant to evaluate their own products.<br /><br />But here in the States, we are probably too diverted by yelling at each other about whether a "public option" is vital or nefarious to worry about such issues.. Meanwhile, expect our health care to continue to get more expensive, less accessible, and less good for patients.<br /><br />ADDENDUM (25 August, 2009) - Also, see the <a href="http://brodyhooked.blogspot.com/2009/08/sifting-through-garbage-to-find-science.html">comments</a> by Dr Howard Brody on the Hooked: Ethics, Medicine and Pharma Blog<br /><br /><strong><span style="font-size:85%;">References</span></strong><br /><span style="font-size:85%;"></span><br /><span style="font-size:85%;">1. Stone M, Laughren T, Jones ML et al. Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration. Brit Med J 2009; 339: b2880. Link </span><a href="http://www.bmj.com/cgi/content/full/339/aug11_2/b2880"><span style="font-size:85%;">here</span></a><span style="font-size:85%;">. </span><br /><span style="font-size:85%;">2. Depression Guideline Panel. Depression in Primary Care: Volume 2 - Treatment of Major Depression. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1993. Link </span><a href="http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.chapter.15593"><span style="font-size:85%;">here</span></a><span style="font-size:85%;">.</span><br /><span style="font-size:85%;">3. Ambulatory Care Quality Alliance. Recommended Starter Set: Clinical Performance Measures for Ambulatory Care. </span><a href="http://www.ahrq.gov/qual/aqastart.htm"><span style="font-size:85%;">http://www.ahrq.gov/qual/aqastart.htm</span></a><br /><span style="font-size:85%;">4. Kondro W. Drug company experts advised staff to withhold data about SSRI use in children. Can Med Assoc J 2004; 170: 783. Link </span><a href="http://www.cmaj.ca/cgi/content/full/170/5/783"><span style="font-size:85%;">here</span></a><span style="font-size:85%;">.</span><br /><span style="font-size:85%;">5. Wadman M. Sptizer sues drug giant for deceiving doctors. Nature 2004; 429: 589. Link </span><a href="http://www.nature.com/nature/journal/v429/n6992/full/429589a.html"><span style="font-size:85%;">here</span></a><span style="font-size:85%;">.</span><br /><span style="font-size:85%;">6. Hammad T, Laughren T, Racoosin JA. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry 2006;63:332-9. Link </span><a href="http://archpsyc.ama-assn.org/cgi/content/full/63/3/332"><span style="font-size:85%;">here</span></a><span style="font-size:85%;">.</span><br /><span style="font-size:85%;">7. Turner EH, Matthews AM, Linardatos E et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 2008; 358: 252-260. Link </span><a href="http://content.nejm.org/cgi/content/full/358/3/252"><span style="font-size:85%;">here</span></a><span style="font-size:85%;">.</span>

High Costs and Poor Outcomes - A Lesson About the Suppression of Research

Last week, blogger Alison Bass was one of the few to comment on a new article on the risks of antidepressant medications published electronically last week by the British Medical Journal.[1] The artic…

Đọc thêm »

JAMA Editors Try Attacking the Messenger

Early this month, yet another story surfaced about allegations of undisclosed conflicts of interest affecting the author of a highly publicized clinical trial. This story has now taken such an odd twist that it seems worth discussing in some detail. Let me first try to present some relevant facts, derived from published articles, mainly peer-reviewed, which do not seem to be in dispute, in chronological order.<br /><br /><em>2005 </em>- In a multi-author review article on mood disorders in the medically ill, Dr Robert G Robinson, of the University of Iowa, disclosed that he served on the speakers bureau of Forest Laboratories.(1) In an article in Stroke: Clinical Updates, he made a similar disclosure.(2)<br /><br /><em>28 May, 2008</em> - Dr Robinson was the first author of an article published in JAMA that described a randomized controlled trial comparing placebo, problem-solving (cognitive talking) therapy, and escitalopram (Lexapro, Forest Laboratories) in the prevention of depression in patients who have had strokes.(3) Patients who received placebo had a higher rate of depression (11 major, 2 minor cases, 22.4%) than patients who received escitalopram (3, 2, 8.5%) or who received problem-solving therapy (5,2, 11.9%). At the end of the article, Dr Robinson disclosed, "over the past 5 years, Dr Robinson reports serving as a consultant to the former Hamilton Pharmaceutical Company and Avanir Pharmaceutical Company," but made no disclosure about any financial relationship with Forest. In a news article published the day before, Dr Robinson was quoted as saying, "I think every stroke patient who can tolerate an antidepressant should be given one to prevent depression," but did not advocate the use of problem solving therapy.(4)<br /><br /><em>15 October, 2008</em> - In a letter to JAMA, Lacasse and Leo asked whether Robinson et al had done an analysis directly comparing problem-solving therapy and escitalopram, and noted that the reported incidence data for stroke in the two treatment groups suggest that the difference in treatment results "does not appear to be either clinically or statistically significant."(5) Robinson et al responded that there was no statistically significant differences between the groups.(6)<br /><br /><em>5 March, 2009</em> - In a rapid response section in the British Medical Journal, Leo and Lacasse raised their concerns about the interpretation of the results of the 2008 trial, and also stated that "during a subsequent internet search we were surprised to learn that four years previously the lead author had been listed on the speaker's bureau for Forest. The omission, however innocent or mistaken, is disturbing; neither the JAMA article nor subsequent media accounts noted that the lead author had served on the speaker's bureau for the manufacturer of Lexapro."(7) Their citation was to our reference 2.<br /><br /><em>11 March, 2009</em> - In a letter to JAMA, Robinson and Arndt reported that the financial disclosure for their 2008 article was incomplete, "resulting from erroneous recollection of the appropriate dates for speaking presentations sponsored by pharmaceutical companies...."(8) Dr Robinson disclosed receiving honoraria for two presentations in 2004, and serving on the Forest Laboratories speakers bureau "in 2004 and perhaps 2005." No editorial comment accompanied this letter.<br /><br />So far, this seems to be a familiar story about an author who seemed to be excessively enthusiastic about a product of the company with whom he had had a financial relationship, but reluctant to disclose this relationship. But wait,<br /><br /><em>20 March, 2009</em> - A rather extraordinary editorial was published electronically in JAMA on 20 March, 2009.(9) Let me review its main points, section by section.<br /><br />After acknowledging the attention conflicts of interest now receive, and briefly describing the 2008 study and the subsequent letter by Lacasse and Leo, the editorial stated that JAMA editors had received a communication from Leo on or after 16 October, 2008 which "indicated he had evidence that Robinson had not reported in his article that he had served on the speakers bureaus for pharmaceutical companies."<br /><br />The editorial then devoted several paragraphs explaining the "due diligence" JAMA editors used to investigate this "allegation." They noted the "sensitive nature of these investigations," which required them to conduct them "confidentially," and again insisted "these investigations into undisclosed conflicts of interest are time-intensive and require careful attention." Thus, from the time Leo sent his "allegations," (apparently 16 October, 2008), it took until 31 January, 2009 to get a letter from Robinson et al acknowledging his undisclosed conflicts, and until 11 March, 2009 to publish it, a total of five months.<br /><br />However, the concerns with confidentiality, and the repeated emphasis on the need for unusually painstaking investigation seemed disconnected to the particular case. It is clear that it may take quite a bit of time and effort to investigate some allegations of undisclosed conflicts of interest, especially when the allegations are vague, but the alleged conflicts are severe. However, in this case, it should have taken trivial effort to find Dr Robinson's previous, published disclosures. (It took me about 5 minutes of internet searching to find the two 2005 articles.) Once (easily) discovered, the disclosures in the 2005 articles starkly contrast with the disclosures, or lack thereof in the 2008 article. Furthermore, since these disclosures were already in the public domain, there should have been no concerns with confidentiality.<br /><br />Nonetheless, the editors then asserted:<br /><br /><blockquote><br />While the <em>confidential investigation of unreported conflicts of interest is under way, we consider involvement of third parties— such as Leo had done by his posting on the BMJ site and by contacting the media—to be a serious ethical breach of confidentiality </em>that not only potentially <em>damages our ability to complete a fair and thorough investigation</em> (of the specific issue that Leo had brought to our attention), but also <em>potentially damages JAMA’s reputation by the insinuation that we would fail to do so.<br /></em></blockquote><br /><br />This makes no sense. There was no need for confidentiality, because the allegations were not based on whistle-blowing or confidential information. They were based on published articles, articles which clearly disclosed Dr Robinson's financial ties to Forest Laboratories. Anyone who bothered to do a simple Google search could have found that Dr Robinson's disclosure in his 2008 JAMA article did not agree with his disclosure in several 2005 articles. Lacasse and Leo used no confidential information whatsoever in making their allegations. Actually, they were not making "allegations," but simply pointing out that an author had published statements which were inconsistent. Since Lacasse and Leo were simply pointing discrepancies among published articles, how could they have breached "confidentiality," ethically or not?<br /><br />Second, there was no need for a complex or prolonged investigation. The discrepancies were apparent as soon as one viewed the published articles side by side.<br /><br />The third point was a non sequitur, and a classic example of blaming the messenger for the message. JAMA had published an article. Other journals published other articles. Publishing these articles put them in the public domain. If comparison of these articles in the public domain were to reflect badly on on of their publishers, it would not be the fault of making the comparison.<br /><br />Regardless of the illogical nature of their concerns with non-existent confidentiality, assertions that it takes a long, complex investigation to demonstrate the obvious, and their aspersions on the messenger for the message, the JAMA editors then revealed that:<br /><br /><blockquote><br />A telephone conversation intended to inform Leo that his actions were inappropriate <em>transformed into an argumentative discussion</em>, as <em>Leo continued to refuse to acknowledge any problems with his actions</em>, even after he was informed that the investigation was completed and was advised to read the upcoming March 11 issue of JAMA (where the letter of explanation and apology from Robinson and the formal correction were in press).<br /></blockquote><br /><br />Furthermore, the editors proposed punishing Leo, first by effectively banning him from publishing in the pages of JAMA,<br /><br /><blockquote><br />Leo also was informed that, if his actions represented his apparent lack of confidence in and regard for JAMA, he certainly should not plan to submit future<br />manuscripts or letters for publication.<br /></blockquote><br /><br />Then, by complaining to his supervisor<br /><br /><blockquote><br />However, since Leo apparently did not appreciate the serious implications of his actions, despite our attempts to explain, we felt an obligation to notify the dean of his institution about our concerns of how Leo’s actions were potentially damaging to JAMA’s reputation. We sought the dean’s assistance in resolving this issue involving a member of the faculty of his institution, to assure there would be no need to publicly identify that faculty member. No dean wants his or her institution implicated in a publication reflecting improper behavior by a faculty member.<br /></blockquote><br />Finally, they seemed bitterly offended that the British Medical Journal would publish anything that disagreed with anything printed in JAMA:<br /><br /><blockquote><br />In addition, we were dismayed that BMJ would post the article by Leo with the allegations against Robinson and the negative insinuations about JAMA, without at least contacting JAMA to verify the veracity of the report.<br /></blockquote><br />Again, rather than raising unsubstantiated allegations, Leo and Lacasse's letter to the BMJ simply showed the discrepancy between the disclosures in Robinson and colleagues' 2008 JAMA article and those in one of his 2005 articles. Both articles are publicly available. What useful information about the letter above and beyond that provided by viewing the discrepant articles could the JAMA editors have provided?<br /><br />While the JAMA editors castigated Leo for unethical behavior, and sought to punish him for it, they said nothing negative about Robinson. Yet it was Dr Robinson who was supposed to disclose his conflicts to JAMA, but who managed to forget conflicts that he had disclosed before. Why would would it be more unethical to point out publicly available evidence about failure to disclose conflicts of interest than to conceal these conflicts in the first place?<br /><br />This story is saddening. JAMA has published many important and useful articles on conflicts of interest, and other matters relevant to Health Care Renewal. We have probably favorably cited more editorials by JAMA on these topics than those in any other journal. Yet now the journal's leadership seems to have somehow lost their way. Instead of trying to constructively respond to criticism, they now seem intent on punishing the critics. I hope they find their compass soon, before an important medical institution really is irreparably damaged.<br /><br /><br />Note: another detailed analysis of this case is <a href="http://brodyhooked.blogspot.com/2009/03/jama-editors-need-to-come-down-off.html">here</a> in the Hooked: Ethics, Medicine and Pharma blog. <a href="http://online.wsj.com/public/resources/documents/leo_statement_for_WSJ.htm">Here</a> is Professor Leo's response to the JAMA ediorial.<br /><br />ADDENDUM (24 March, 2009) - see also<a href="http://scienceblogs.com/insolence/2009/03/catherine_deangelis_and_jama.php"> the extensive analysis </a>of this case on the Respectful Insolence blog, and the comments <a href="http://scienceblogs.com/effectmeasure/2009/03/jamas_editors_make_sewage_out.php">here</a> on the Effect Measure blog, <a href="http://www.gooznews.com/archives/001359.html">here</a> on Gooznews, and <a href="http://www.kevinmd.com/blog/2009/03/jama-versus-jonathan-leo-debacle.html">here</a> on KevinMD.<br /><br />References<br /><br />1. Evans DL, Charney DS, Lewis L et al. Mood disorders in the medically ill: scientific review and recommendations. Biol Psychiatry 2005; 58: 175-189. [Link <a href="http://userwww.service.emory.edu/~jdbremn/papers/evans_mooddisorders.pdf">here</a>.]<br />2. Robinson RG, Zorowitz RD. Pseudobulbar affect and stroke. Stroke: Clinical Updates 2005; XV (Jan-Feb). [Link <a href="http://www.stroke.org/site/DocServer/SCU_-_Jan-Feb_2005.pdf?docID=5161">here</a>.]<br />3. Robinson RG, Jorge RE, Moser DJ et al. Escitalopram and problem-solving therapy for prevention of poststroke depression: a randomized controlled trial. JAMA 2008; 299: 2391-2400. [Link <a href="http://jama.ama-assn.org/cgi/reprint/299/20/2391">here</a>.]<br />4. Elias M. Study: antidpressants help stroke victims. USA Today, May 27, 2008.<br />5. Lacasse J, Leo J. Escitalopram, problem-solving therapy, and poststroke depression. JAMA 2008; 300: 1757-1758.<br />6. Robinson RG, Jorge RE, Arndt S. Escitalopram, problem-solving therapy, and poststroke depression. JAMA 2008; 300: 1758-1759.<br />7. Leo J, Lacasse J. Clinical trials of therapy versus medication: even in a tie, medication wins. Brit Med J, 2009: 338: b464. [Link <a href="http://www.bmj.com/cgi/eletters/338/feb05_1/b463">here</a>.]<br />8. Robinson RG, Arnd S. Incomplete financial disclosure in a study of escitalopram and problem-solving therapy for prevention of poststroke depression. JAMA 2009; 301: 1023-1024. [Link <a href="http://jama.ama-assn.org/cgi/content/full/301/10/1023-a">here</a>.]<br />9. DeAngelis CD, Fontanarosa PB. Conflicts over conflicts of interest. JAMA 2009; 301: [Link <a href="http://jama.ama-assn.org/misc/jed90012pap_E1_E3.pdf">here</a>.]

JAMA Editors Try Attacking the Messenger

Early this month, yet another story surfaced about allegations of undisclosed conflicts of interest affecting the author of a highly publicized clinical trial. This story has now taken such an odd twi…

Đọc thêm »

Curiouser and Curiouser - the Case of the Allegedly Missing Prozac Documents

The case of the <a href="http://bmj.bmjjournals.com/cgi/content/full/330/7481/7?ehom">BMJ news article about missing Prozac documents</a>, which <a href="http://hcrenewal.blogspot.com/2004/12/another-facet-of-ssri-suppression-of.html">we have discussed before</a>, just gets curiouser and curiouser.<br />Today, the NY Times published a news article that seems to suggest something big went wrong at the BMJ. <a href="http://www.nytimes.com/2005/01/17/business/media/17journal.html">"Dispute Puts a Medical Journal Under Fire," by Barry Meier</a>, asserted "the staid, usually methodical world of medical journals could suffer its own black eye," and that "the incident may prove to be a messy one for the BMJ."<br />But Meier produced little evidence to support these apparently quasi-editorial conclusions.<br />Let's go back to the <a href="http://bmj.bmjjournals.com/cgi/content/full/330/7481/7?ehom">original BMJ article</a>. Its key assertions were that<br />"confidential drug company documents ... went missing during a controversial product liability suit more than 10 years ago;" "the documents appear to suggest a link between the drug fluoxetine (Prozac), made by Eli Lilly, and suicide attempts and violence;" and "Eli Lilly officials were aware in the 1980's that fluoxetine had troubling side effects and sought to minimise their likely negative effects on prescribing."<br /><a href="http://www.nytimes.com/2005/01/17/business/media/17journal.html">Meier's NY Times news article </a>reported that Eli Lilly vigorously contested the content of the BMJ article. Specifically, its lawyers "notified the publication that the company considers the article to be 'inaccurate and defamatory,' asserting that the records were not missing and that all their relevant data had been previously submitted to the FDA. Also, Lilly issued an analysis last week of the 52 pages of records that the BMJ had received, which the company said supported its claims." Yet Meier's article does not give any specifics of how Lilly disputed the main points of the BMJ article. So apparently Meier concluded that the BMJ deserved a "black eye" just because Lilly did not agree with it. Why he seemed to think that Lilly was right and the BMJ was wrong, especially without seeing the documents in question, is not clear.<br />Furthermore, other statements by Lilly, available on <a href="http://www.lilly.com/">its web site</a>, muddy things further.<br /><a href="http://newsroom.lilly.com/ReleaseDetail.cfm?ReleaseID=151873">Lilly's press release of January 4, 2005</a>, asserted that the "documents reveal no new clinical or scientific information," and that "the information in the documents has already been shared with the U.S. Food and Drug Administration (FDA) and other regulatory bodies, published in medical journals, or produced through legal discovery and available for use at various legal trials for more than a decade." Of course, this did really address the BMJ's assertion that specific documents went missing. Furthermore, information produced through legal discovery may not be sufficiently available to physicians to affect their prescribing decisions.<br /><a href="http://newsroom.lilly.com/ReleaseDetail.cfm?ReleaseID=152743">The second Lilly press release of January 13, 2005</a>, contains an assertion by Lilly CEO Sidney Taurel that "it is simply wrong to suggest that information on Prozac was ever missing or that important research data on the benefits and possible side effects of the drug were not available to doctors and regulators." Lilly complained about "the media reports stating that Prozac is 12 times more likely to cause suicide than other, older antidepressants" as "patently false." The BMJ news article, however, contained no such claim. Taurel's statement seems to be an attempt to declare guilt by association. (Perhaps Taurel was referring to a <a href="http://i.cnn.net/cnn/2005/images/01/03/eli.lilly.pdf">document posted by CNN </a>that purports to show a suicide attempt rate of 3.7% for fluoxetine vs. 0.8% for amitryptiline, and 0.2% for trazadone.)<br />More curiously, the press release stated "Lilly is calling on the BMJ to make the full documents available to the media and other interested parties." However, in its <a href="http://www.lilly.com/news/pdf/pz_annotations_1_12_05_final.pdf">accompanying "analysis"</a>, Lilly itself declined to make the actual documents public, stating "due to court orders requiring confidentiality of some of the documents contained within the 52 pages, Lilly is unable to relsease the 52 pages of documents." But then did Lilly mean to call on the BMJ to violate a court order? This statement, of course, also contradicts Sidney Taurel's assertion that all relevant information in the documents was freely available to doctors and regulators. How were doctors supposed to access information that was rendered "confidential" by court order?<br />Thus, there is nothing I can find so far in Lilly's media barrage that refuted the claim made by the BMJ news article that Lilly had tried to prevent data on adverse effects of fluoxetine from affecting doctors' prescribing decisions. And I cannot figure out why a NY Times reporter decided that it was the BMJ, not Lilly, who figuratively earned a "black eye."<br />Finally, let me state again, we should not let smoke and mirrors distract us from the fundamental issue that suppressing and/or obfuscating information about adverse effects of drugs is bad for patients, bad for doctors, bad for science, and bad for society.

Curiouser and Curiouser - the Case of the Allegedly Missing Prozac Documents

The case of the BMJ news article about missing Prozac documents, which we have discussed before, just gets curiouser and curiouser.Today, the NY Times published a news article that seems to suggest so…

Đọc thêm »