Tuesday, March 05, 2013

What's Missing in Scientific Journal Articles on New Innovations in Medicine

My perspective on scientific publications has been greatly affected by my experience with this blog and social media in particular.  The ability to serve as author, reviewer, advertiser and marketer can be easily achieved in this space thanks to the power of self-publishing.  But with this new platform comes new responsibilities and for those of us who chose to work with people daily, perhaps none is as great as maintaining the trust of our patient readers.

This week's New England Journal of Medicine opened my eyes to another revelation in scientific reporting where doctors have not been completely honest with our patients.  While few are as enamored with scientific innovation as myself, I find there is an gaping hole in scientific discourse that doctors have not forced to the surface when new innovations arise.

What's that hole?


In an era where scientific discovery has only been eclipsed by price inflation, doctors have not taken responsibility for insisting this cost of any new innovation's impact on our health care system be disclosed in scientific articles reviewing the medication's risks and benefits.   We have not insisted that major medical journals reveal which articles are provided free to the public through tacit collusion with their pharmaceutical sponsors.  (While the exact price might not be known at the time of publication of these articles, the estimated cost to our health care system can probably be guessed depending on the novelty of the medication or device and the expected return on investment a manufacturer would hope to achieve.)  To be fair, most reputable journals do require disclosure of manufacturer's sponsorship of the reported trial, but no where do the journals report the money they receive from those same manufacturers for making favorable articles about a drug or device open access to the public.

Take this week's New England Journal of Medicine.: Three articles appear on our new novel oral anticoagulants that lack cost information and disclosure information from the journal regarding if they paid for the article to be open access:
Apixiban for Extended Treatment of Venous Thromboembolism: The article is open access and not a word about the cost of the drug.  Did Bristol-Myers Squiibb or Pfizer (or both) pay to be sure this article was open to all?

Extended Use of Dabigatran, Warfarin or Placebo for Venous Thromboembolism: The article is open access and not a word about cost of the drugs.  Did  Boehinger Ingelheim pay to be sure this article was open to all?

Rivaraoxaban for Thromboprophylaxis in Acutely Ill Medical Patients: The article is open access and not a word about the cost of the drugs.  Did Bayer Healthcare Pharamceuticals and Janssen Research and Development pay to be sure this article was open to all?

Increasingly I find the cost of these novel oral anticoagulants relative to warfarin factors in to conversations I have with patients during their decision about which drug to start.  Granted, it is just one factor, but an important one.  I also find the deluge of pharmaceutical benefit manager denial letters to be a real thorn in my side as I have to constantly justify to payers why one drug has better benefits for an individual patient than another.  Not being armed with cost information puts me at a disadvantage when speaking with these deterrents to care.  The reality is this: we simply HAVE to have honest discussions with our patients about cost these days, especially since more and more costs for care are being shouldered by our patients than ever before and the financial impact of their care has huge psychological implications.  If I have to disclose everything about my relationship with industry thanks to the Sunshine Law, our scientific journals should do the same.

It is for this reason that we should insist on at least relative cost information of new technologies appear in scientific reporting, especially when the cost of new innovations exceed existing innovations by over a factor of 10.  In this era of health care reform and growing cost concerns, patients (and their doctors) deserve disclosure of at least a relative benchmark of price so we can make the best informed medical treatment decisions with our patients that benefits not only their physical well-being, but also their psychological and social well-being too.



Stephen Welch said...

I'm confused - I tried to access those NEJM articles but only the abstract was openly accessible. The remainder o the article was under NEJM access control to subscribers.

Anonymous said...

I couldn't access the full articles either, but I followed and appreciated your point. My sincere thanks.

Anonymous said...

Hooray! Now you're getting it, doc. Cost is critical and must be part of the conversation. Can't wait until we get the hospitals included in these disclosures.

medicine for real said...

The cost should be a major part of the conversation. the ACA is supposed to be starting more research on comparative effectiveness for various treatments. These evaluations should also include honest comparisons of the cost/benefit of each treatment. Newer is not always better and is usually more expensive. Robotic prostate surgery comes to mind