A new article in the British Medical Journal describes the endemic problem of industry influence in healthcare. The authors argue that industry influence compromises the integrity of unbiased evidence, and suggest ways to achieve independence from such control.
Led by Ray Moynihan of Bond University, Australia, the article is written by clinicians, researchers, and citizen advocates from across the globe. They write that the current evidence-building process in the healthcare industry is riddled with conflicts of interest, which results in overdiagnosis, overtreatment, and overtesting of the patients.
The problem of industry influence in the healthcare sector is well-known, as reflected in the medical community’s recent initiative to address the dangers associated with polypharmacy. Researchers have also pointed to the conflicts of interest, which influence how new categories of psychiatric diagnoses are created. Both DSM IV and the DSM V have been criticized for panel members having financial ties with pharmaceutical companies. The inclusion of pre-menstrual dysphoric disorder into mood disorders and the introduction of hypoactive sexual desire disorder are considered some such moves.
Additionally, these conflicts find their way into how clinicians then utilize these diagnoses. For example, the industry influence that led to the creation of bipolar disorder in children was followed by a 40-time increase in the diagnosis of the disorder. This is a profoundly worrying trend considering new research, which suggests that patterns of psychiatric diagnosis are influenced by a patients’ race and socioeconomic status.
The authors of this article point to the 2009 landmark study, which revealed a deep and pervasive problem of industry conflict when it comes to education, research, and practice of medicine. They write:
“We argue that endemic financial entanglement is distorting the production and use of healthcare evidence, causing harm to individuals and waste for health systems.”
Over 60% of medical research in America is industry-funded, and evidence suggests that such funding creates a sponsorship bias because results usually benefit the sponsors. As the New York Times report on bipolar disorder in children had shown, Harvard psychiatrist Joseph Biederman had conveyed to Johnson and Johnson that “planned studies of its medicines in children would yield results benefiting the company.”
Apart from giving in to sponsorship companies’ desire for positive results, the authors suggest that other loopholes can be exploited, intentionally or not, to produce favorable results. These include unfair study designs and publication bias. This is disconcerting since research shows that published studies already show evidence of considerable spin in their abstracts.
A similar bias is found in education where industry-funded advocacy groups tend to be favorable towards sponsors’ products. They can distort the narrative through which they educate the public, and remain uncritical of their funders. A recent example would be how Sprout pharmaceuticals employed a marketing campaign that co-opted the feminist discourse to make a failed antidepressant get FDA approval as female Viagra.
Lastly, this effect is prevalent in clinical practice where pharmaceutical representatives influence the prescriber’s behavior and attitude towards the drug. For example, studies suggest that marketing payments by opioid pharmaceuticals to doctors led to higher prescriptions and higher death rates. Other ways to influence doctors is by changing guidelines to widen the definitions of what constitutes a particular disease, which can lead to overdiagnosis and inappropriate treatment. The authors write:
“To make matters worse, regulatory agencies that evaluate research evidence – including the European Medicines Agency and the US Food and Drug Administration – also have financial conflicts of interests as they rely on funding from companies whose products they are evaluating.”
Acknowledging the scope and depth of these problems, the authors suggest ways to disconnect from industry influence to protect the integrity of the treatment. They especially encourage a separation between those creating the products and those evaluating the efficacy of the same.
They suggest several possible measures to increase independence from industry influence. For research, they propose that governments should enforce independent evidence finding when it comes to healthcare research and that they should ensure public regulatory bodies and assessors remain entirely segregated from industry funding.
Additionally, they suggest complete transparency in providing information about methodology, results, and clinical reports to those performing systematic reviews, and further making sure that reviewers have no relations with drug companies. They give the example of Cochrane, which now has guidelines in place to ensure that for systematic reviews, at least two-thirds of authors must be independent and free of industry connections.
The authors further propose that advocacy and academic groups, which attempt to educate the public about various conditions and can influence policy-making and national narratives, remain entirely free of any ties with the industry. Some researchers have already critiqued this form of propaganda in psychiatry. Further, medical journals and licensing bodies must also discontinue their dependence on industry funding, and more importantly, accreditation of professionals must not be premised upon industry influenced educational work. Some of these programs which separate industry sponsorship from educational activities are already in place:
“Following campaigning by family doctors, the Norwegian Medical Association ruled that industry sponsored meetings and courses could no longer be counted as formal education, necessary for accreditation,” the authors write.
In terms of practice, the authors propose that government bodies and hospitals themselves ban any marketing contact between industry representatives and practitioners. This includes ensuring healthcare guidelines remain untainted from the influence of industry-backed groups. Lastly, academic institutions must take it upon themselves to encourage researchers and clinicians to collaborate with public agencies rather than only depending on industry groups. The authors point to doctors’ groups such as No Gracias, No Advertising Please, and Mezis; these have taken a stand against industry influence by using information that is created independently.
The authors recommend that an essential initial step would be to create and enforce laws that force complete disclosure of any payments between drug companies and bodies which assess and evaluate a product. While these steps are essential, past research has shown that mere disclosure and even complete transparency do not necessarily reduce bias. For that matter, evidence has shown that researchers regularly minimize their conflict of interest disclosures.
The authors also acknowledge that while they have focused on financial relationships as conflicts of interest, there are other non-financial ways in which industries impact research, practice, and education in healthcare.
In conclusion, unbiased evidence is the only way to ensure that the benefits and harms of various treatments are accurately reported, and this requires comprehensive scrutiny of the process, which influences policy decisions at a national level and diagnostic ones at the individual level.
Moynihan, R., Bero, L., Hill, S., Johansson, M., Lexchin, J., Macdonald, H.… Godlee, F. (2019). Pathways to independence: towards producing and using trustworthy evidence. British Medical Journal. First published online: 3 December 2019. DOI: 10.1136/bmj.l6576 (Link)