Can we trust health-related media to deliver clean, clear health advice?
FREQUENTLY THE MEDIA does a fabulous job of informing the public on health-related matters. Many Canadians trust health journalists to deliver factual and important assessments of new drugs and other medical treatments. But sometimes they miss the mark by a wide margin and deliver messages that threaten to turn more people than ideal into patients.
The most recent example comes via one of CBC’s house doctors, Dr Peter Lin, who frequently appears on CBC radio talking about medical matters. A few months back, he spoke about a new trial around blood pressure-lowering which suggested that there were millions of Canadians who needed to be working even harder to bring their blood pressures down. He was referring to a trial which generated a lot of media coverage called SPRINT, which examined this question. In our assessment, his interpretation of that study was completely backwards.
A quick search of the medical literature revealed that Dr Lin is not only a CBC regular commentator on medical affairs, but also consults with several drug companies—18 to be exact. His online bio discloses that he has consulted with Astra Zeneca, Bristol Myers Squibb, Takeda, Purdue, Boeringher Ingelheim, Bayer, Eli Lilly, Amgen, Jansen, Forest Laboratories, J&J, Merck, Novartis, Pfizer, Servier, Sanofi, Abbott, Mylan, and that he also does continuing medical education for the companies. These drug companies pay him.
It is common for researchers or physicians to have financial conflicts of interest related to the pharmaceutical industry. We know that those conflicts can affect drug recommendations. In fact, most high-quality evidence on this issue comes to the same conclusion: compared to non-conflicted commentators, those with ties to the drug industry have much more positive opinions about the good effects of drugs, and tend to ignore or downplay the adverse effects of those drugs. Furthermore, they are more likely to recommend more costly, branded drugs rather than cheaper generic or non-drug options. These facts are supported by decades of research on drug marketing, and are at the heart of the drug industry’s return on investment (ROI) analyses. Those ROI analyses demonstrate that investing in key opinion leaders, such as Dr Lin, is a useful strategy that delivers high returns: more prescriptions and more revenues.
When I (Alan) complained in an email to the CBC Ombudsperson about the CBC not dislosing Dr Lin’s conflicts of interest, a managing editor at CBC News acknowledged the importance of the issue, but stated, “The issue is not, then, whether Dr Lin has relationships with private companies. It’s whether those relationships create a conflict by influencing the medical decisions he makes—and in particular whether they affect the advice he gives our listeners. To that point, we are not aware of any such conflict affecting the work he has done for us. If you have a specific such instance to flag for us, we would be happy to look into the circumstances.”
My follow-up letter will address the SPRINT example.
One of the most contentious areas of drug utilization is the use of pharmaceuticals to lower blood pressure. It is true that high blood pressure can raise the risks of stroke and heart attacks, an association that has been known for years. The question anyone with high blood pressure might have is this: How low do I need to go? In other words, what optimal target blood pressure should I be aiming for if I want to maximize the length and quality of my life?
In a city like Victoria, with many older adults who have been told they have “high” blood pressure, or hypertension, this is not a moot point. Too aggressively lowering blood pressures in older people can be serious because it can lead to dizziness, falls and fractures. Our research found that most of the trials of blood pressure medications are on younger, healthier populations, and so cannot be extrapolated to older, more frail people where slightly higher blood pressure is normal.
The largest trials in an older population suggest being very conservative with treatment. One Swedish study of individuals over 85 said that the ideal systolic blood pressure is in the range of 140 to 160 mmHg. In other words, the sweet spot of ideal blood pressures changes as you get older, and doctors should not try to treat your grandmother’s blood pressure like she was 20 years old.
On this subject, Dr Lin quoted on CBC from the SPRINT trial, a trial designed to answer the question of the optimal blood pressure target. He discussed how this study showed that aiming to get blood pressure levels to a lower target (say around 120 systolic, the upper number) is a strategy that would save more lives. Urging those with “moderate” high blood pressure to do what they can—sometimes taking three or even four different antihypertensive drugs—to achieve these lower targets is a message the pharmaceutical industry would appreciate.
What he didn’t mention is that the best answer to this question doesn’t come from a single study, it comes from examining the global body of studies designed to answer the question. He failed to mention there was a published Cochrane Review on this question of blood pressure targets. That review, which summarizes the best available evidence, concluded “treating patients to lower than standard BP targets,” (that is, less than 140-160/90—100 mmHg), “does not reduce mortality or morbidity.”
Our researchers with the Therapeutics Initiative at UBC have analyzed the SPRINT trial. Contrary to Dr Lin’s opinion, that analysis found that the benefits of lower blood pressure targets do not outweigh the harms. In fact, in the SPRINT trial, the magnitude of the harms was greater than the magnitude of the benefits. (ti.ubc.ca and search for “SPRINT.”)
The main thing you should know is that we are not alone. Hundreds of researchers around the world are involved in deeply analyzing drug trials as part of groups like the Therapeutics Initiative, and the Cochrane Collaboration. They work independently from pharmaceutical industry funding, and cautiously examine the evidence of drug effects. If physicians want to be credible, authoritative and trustworthy media commentators about drugs, they need to refer to the best, least-biased information possible, looking at the totality of evidence, not single trials that are islands unto themselves.
Is it even reasonable to expect an unbiased view of drug therapy effects from spokespeople who have multiple close ties to pharmaceutical companies? We would never expect this in other domains: think about an expert from the oil and gas industry talking about global warming, or a judge deciding the merits of a case, but not telling anyone he was married to the defendant, or owed the defendant money. Certainly you would call those flawed, potentially-biased situations.
The same is true with the pharmaceutical industry, where funded experts with financial ties are more likely to see the evidence a certain way. When physicians or other media spokespeople speak about medical matters, we should expect nothing less than full disclosure about any ties to makers of drug products. Medical media that might be skewed towards the private interest of companies instead of the public interest of citizens has the potential to hurt the people it is intended to help.
Alan Cassels’ disclosure: “I have been an independent pharmaceutical policy researcher for 25 years and have never taken any money from the pharmaceutical industry. I currently work for UBC’s Therapeutics Initiative, which is funded by the BC Ministry of Health, and have, in the past, been paid on contract as a contributor to CBC Ideas and CBC Syndication. I have also authored a book about the Cochrane Collaboration.”
Dr Jim Wright’s disclosure: “I am the founder and Co-Managing Director of the Therapeutics Initiative at UBC and the Coordinating Editor of the Cochrane Hypertension group. Hypertension reviews can be found at www.cochrane.org.”
This article represents the opinion of Alan Cassels and Jim Wright, and should not be construed as an official viewpoint of the Cochrane Hypertension Group or the Therapeutics Initiative.