Another Wrinkle in the Treatment Guideline Controversy

Now, there is another element in the controversy.  What
happens if a corporation essentially buys an undue degree of influence
in the formulation of treatment guidelines?



Treatment guidelines have always promoted controversy in medical
practice.  Most physicians like the idea of a concise
guideline that is based upon empirical data and expert consensus.
 But some resist the idea, thinking that a cookbook approach
is counterintuitive or contrary to their notions of the need to place
an emphasis on the quality of the physician-patient relationship.



Undue corporate influence is the subject of a Perspective
article in the latest NEJM:

href="http://content.nejm.org/cgi/content/short/355/16/1640">Surviving
Sepsis — Practice Guidelines, Marketing Campaigns, and Eli
Lilly

Peter Q. Eichacker, M.D., Charles Natanson, M.D., and
Robert L. Danner, M.D.

Volume 355:1640-1642    
    October 19, 2006
        Number 16



Practice guidelines approved by expert panels are intended to
standardize care in such a way as to improve health outcomes. In recent
years, the developers of such standards have started grouping
evidence-based interventions into "bundles," on the theory that
inducing physicians to follow multiple recommendations written into a
single protocol has a measurable effect on patients' outcomes. As a
side effect, bundled performance measures are ready-made for use in
pay-for-performance initiatives, which can base reimbursement on
compliance with all the components.



Unfortunately, the development of such clusters is vulnerable to
manipulation for inappropriate — and possibly harmful
— ends. Seeing in these bundles a potentially powerful
vehicle for promoting their products, pharmaceutical and medical-device
companies have begun to invest in influencing the adoption of
guidelines that serve their own financial goals. A case in point is the
development of guidelines for the treatment of sepsis, which was
orchestrated as an extension of a pharmaceutical marketing campaign....

This is a highly disturbing development.  Just like
pharmaceutical company involvement in continuing medical education, it
threatens to undermine the integrity of medical practice, and threatens
the credibility of sources of information that we would like to be able
to trust implicitly.  



Note also the implication for the pay-for-performance aspect of
practice.  I've never been a fan of the concept of
pay-for-performance, mostly for other reasons, but this is yet another
reason to be suspicious of the practice.