Tuesday, March 27, 2012

IN MY VIEW: Joint Commission Policy on Treating Smokers Removes Autonomy from Physicians to Give More Money to Big Pharma

As I discussed here last week, in an article published in the New England Journal of Medicine, Dr. Michael Fiore and colleagues defend the new Joint Commission tobacco cessation performance measure set for hospitals, which - strikingly - insists that every smoking patient be discharged with a prescription for a smoking cessation drug (unless it is specifically contraindicated or the patient refuses).

Today, I explain why this policy is misguided and how unfortunately it is that the policy results from an expert panel chair with multiple financial conflicts of interest with Big Pharma.

The Rest of the Story

Physician autonomy is one of the most important factors that I believe is essential to ensure the quality and integrity of medical care. When autonomy to treat patients in the best interest of the patient is taken away from physicians for any reason, whether it be economic or political, it erodes the quality of medical care, undermines the physician-patient relationship, and threatens to undo the essential element of medical practice upon which the entire practice relies.

This is precisely what has happened with the Joint Commission standard for the treatment of smoking cessation among hospitalized patients. Rather than allow each physician to treat his patient in the way he see fits, the Commission policy requires the physician to treat his patient by prescribing, at discharge, a smoking cessation drug.

I can think of no other area of medical practice where physician autonomy has been so completely taken away by the Joint Commission. If a patient is admitted with hypertension, the physician can treat the patient in any way she sees fit. That may involve an anti-hypertensive drug, but it may also involve weight loss and diet modification. In many cases, diet modification and weight loss are sufficient to control blood pressure, and a drug prescription may not be required. Can you imagine if the Joint Commission required every doctor to prescribe an anti-hypertensive medication at discharge? That would destroy physician autonomy, although it would be a boon for the pharmaceutical companies that make anti-hypertensive drugs.

If a patient is admitted with type II diabetes, the physician can make a judgment about what treatment plan is best for that particular individual. For some, a glucose-controlling drug will be required. For others, weight loss alone may be enough to solve the problem. It is up to the physician to take the particular patient into account and make the decision that is in the best interest of her patient. No one in an unbiased frame of mind would require the physician to prescribe a drug when there are other possible modes of treatment that could be effective.

If a patient is admitted with depression, it is up to the physician to decide whether an anti-depression drug is appropriate, or whether psychotherapy or other treatment modalities are most appropriate for that particular patient. Not so with the Joint Commission's treatment of smoking cessation. Unlike all of the above examples, drug treatment is mandated, regardless of whether the physician believes it is in the best interest of the patient.

That physician autonomy is being undermined would be bad enough. But what makes the situation truly unacceptable is that an apparent reason for this undermining of physician autonomy is the presence of a highly conflicted chair of the advisory panel that helped formulate the smoking cessation treatment criteria. The chair of that panel has a long history of financial conflicts of interest with Big Pharma, especially with companies that manufacture the very drugs that the Joint Commission recommendation is requiring physicians to prescribe.

What a financial windfall for the pharmaceutical companies. They must be laughing all the way to the bank, wondering how lucky they could possibly be that despite the long-standing principle of physician autonomy, somehow the Joint Commission has decided to force doctors to prescribe their drugs to just about every smoking patient. I doubt that even the pharmaceutical companies ever thought they would get that lucky.

The rest of the story is that every dollar that the pharmaceutical companies pay to tobacco researchers for consulting, grants, or honoraria is money well spent. It comes back to the companies in spades, more than offsetting the initial expenditures. This is perhaps the grandest example of the dangers of financial conflicts of interest. In this case, the conflict of interest has not only created a boon for pharmaceutical companies, but it has done nearly the unthinkable: produce an official medical treatment recommendation that disrespects physician autonomy, requiring physicians to prescribe a drug regardless of whether they believe that particular treatment modality is in the best interest of their patient.

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