Tuesday, March 24, 2015

The Atlantic Slams Alcoholics Anonymous--The Carlat Take

The current issue of The Atlantic magazine has a fascinating article entitled "The Irrationality of Alcoholics Anonymous." In a wide-ranging and well-researched article, the author Gabrielle Glaser, begins with the story of a lawyer identified as "J.G."

"J.G." began drinking at age 15 and his habit ramped up through college and law school. Ironically, much of J.G.'s law practice is defending drunk drivers. On a typical court day, according to the article, he would start drinking after his first morning court appearance, and he bought himself a Breathalyzer to make sure he didn't end facing the same judge as his clients. At his worse, he was drinking a full liter of whiskey per day.

Eventually he checked into a rehab based on AA principles. AA famously maintains that complete abstinence is a requirement of effective treatment. It didn't work for J.G., and only led to a series of miserable white-knuckled periods of sobriety interspersed with relapses. Toward the end of the long article we learn that (spoiler alert) J.G. finally gets himself into a clinic that acknowledges the scientific evidence of the efficacy of medications for alcoholism. He is prescribed baclofen and the occasional Valium, and is now successfully sober.

In The Carlat Addiction Treatment Report (CATR) we've written at length about AA and we're generally in agreement with this article. The Cochrane Collaboration, which synthesizes the best evidence available, found only eight RCTs of adequate quality that looked at AA or 12-step Facilitation (TSF), the professional treatment approach that strongly encourages AA participation. The resulting meta-analysis concluded, “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems” (Ferri M et al, Cochrane Database Syst Rev 2006;3:CD005032).

The Atlantic article's timing was perfect for CATR as we just published an issue devoted to integrating medications and therapy in alcoholism treatment. You can read the article on pharmacotherapy for free here

The bottom line is that AA likely works for many people, particularly those who become active in meetings and who get a sponsor. But we know from placebo controlled trials that medications such as naltrexone and acamprosate are effective--and there's no reason not to combine meds with a 12-step program or psychotherapy. 

Saturday, March 21, 2015

On Combining Antipsychotics, Top-Performing Therapists, and Procrastination

I woke up this morning and realized that I've allowed myself to become a victim of BPS--Blog Procrastination Syndrome. It happens to the best of us. We write a post, and days and weeks and months go by. "My next post has to be really, really good," we think.

Forget that. I'm just going to dive back in beginning today. "Done is better than perfect," someone once told me.

At The Carlat Psychiatry Report, we are busy planning future issues, and here are a couple of upcoming topics that I'm fired up about.

Combining Antipsychotics. 

Psychiatrists have gotten plenty of bad PR about our use of antipsychotics. And some of that bad PR is justified. We overuse Seroquel as a sleeping pill. We add too much Abilify to antidepressants because patients come into our office having been hypnotized by ads telling them that this is the drug that will finally help them kick their blues.

But sometimes the criticism is misguided. Lately, guidelines have been published discouraging us from combining antipsychotics. "That's not evidence-based practice," we're told. Fair enough. But when your patient on risperidone is still digging through the snowbanks looking for the transmitter that he's convinced is causing the world to hurtle toward oblivion, you need to something. You can increase the dose, you can switch, you can add, etc....

So I'm working with psychiatric pharmacist Kelly Gable on an article that says, "Look, we understand that combining antipsychotics can increase side effects and is not supported by randomized controlled trials. But sometimes we do it anyway, because our patients our suffering."

We're collecting a list of scenarios that typically lead to antipsychotic polypharmacy, and we're going to evaluate how reasonable these scenarios are. If you have any experience, positive or negative, with antipsychotic polypharmacy, please let me know by email or by commenting to this post.

Top Performing Therapists. 

I interviewed Scott Miller, PhD, the other day for our April issue on psychotherapy. Dr. Miller believes that the real key to improving our clinical success is systematically getting feedback from our patients on how well therapy is going (or medication treatment, or combined treatment, etc....).

He's also found that top performing clinicians spend three to four and a half times as many hours per week than others engaging in "deliberate practice". What does that mean?  You'll have to read about it in the issue. I'm still editing the interview and really enjoying it.

Phew. Feels good to clear out some of the blog-webs that have developed over the months. See you again soon. Really.


Thursday, November 6, 2014

Exploring the link between industry payments to doctors and prescribing habits

This article was originally published in The BMJ on November 5, 2014.

Orthopedic surgeons receive the biggest payments from industry in the US according to the Open Payments database. The next step, writes transparency pioneer Danny Carlat, is for researchers to compare payment data with disclosures of physicians’ prescribing patterns 

After substantial delays, the Open Payments website was launched on 30 September.1 The website was mandated by the Physician Payments Sunshine Act of 2010, and it is a comprehensive registry of payments made to physicians and teaching hospitals by drug and device companies. 

This first wave of reports must be interpreted in light of some data limitations and technical problems. These reports cover only the last five months of 2013, and roughly a quarter of industry payments were not published because of disputed amounts and other factors. Of the payments published, a third have been stripped of the doctors’ names because there were problems ensuring that the payments were accurately attributed to the right recipient. Therefore, only about half of all payments are both published and attributed to identified recipients. The Center for Medicare and Medicaid (CMS), the agency in charge of the database, plans to roll out the missing payments in June of 2015, along with all payments made in 2014.

Although the website is not complete, it still provides unprecedented insight into the extent and nature of financial relationships between physicians and industry. In total, companies paid $3.5bn (£2.2bn; €2.8bn) to 546 000 physicians (about 60% of all US doctors) and to 1360 teaching hospitals over the five months. The largest payments, often in the millions of dollars, went to orthopedic surgeons for royalty payments for inventing or refining surgical products. However, most payments (84%) were small and were for meals and beverages (table).

Breakdown of $3.5bn payments made to US doctors in last five months of 2013
Reason for payment Amount ($)
Research 1.5bn
Physician investors/owners 1bn
General: 1bn
Royalties and licences 302m
Promotional speaking 203m
Consulting 158m
Food 93m
Travel and lodging 74m
Education 36m
Gifts 19m
Interestingly, over 90% of the 300 physicians who were most highly paid for speaking or consulting were men, who comprise only 68% of US doctors. There is no clear explanation for this gender disparity. Women are more likely to work in lower paying specialties such as internal medicine and pediatrics and are underrepresented in specialties that are often recruited by industry for consulting. For example, only 4% of orthopedic surgeons in the US are women.

Wider moves to change behaviour

The Sunshine Act is only a transparency initiative and does not regulate what doctors can or cannot receive. However, the new website has been launched within a broader context of increasing pressure to reform industry payments. Two states, Vermont and Massachusetts, have instituted outright bans on gifts and meals, although the Massachusetts law was repealed because of concerns that local restaurants were losing income. The state’s original gift ban law of 2008 was controversial because it prohibited companies from providing any meals of any value to healthcare practitioners outside a healthcare setting. 

For several years, many of the larger companies have published their own physician payment registries, most of which were required by settlements of lawsuits alleging illegal marketing practices. As these payments have been made public, several companies have decreased their spending for promotional talks, and one company, GlaxoSmithKline, is eliminating such payments altogether.

Like industry, the medical profession is regulating itself. In 2008, the Association of American Medical Colleges published strict conflict of interest recommendations for academic medical centers, which have responded by strengthening their policies. From 2008 to 2014, the percentage of medical schools that ban their faculty from giving promotional talks has increased from 4% to 49%; the percentage of schools banning gifts and meals has also risen sharply. Since 2007, the American Medical Students Association has tracked such conflict of interest metrics in scorecards, which it publishes annually (www.amsascorecard.org). 

Disclosure of payments to doctors is also becoming more common in Europe. The French government, for example, is implementing a disclosure requirement that is similar, though not quite as comprehensive, as the Sunshine Act. In the UK, payment disclosure is based on a voluntary system run by the Association of the British Pharmaceutical Industry, a drug company trade group. Unlike the case in both France and the US, the UK system allows physicians to opt out of disclosure. This opt out provision may prevent meaningful disclosure, depending on the proportion of physicians who use it. Patients may complain that they cannot look up their doctors, and researchers and journalists may have difficulty comparing an individual doctor’s payment with peer averages if the database is incomplete.

Research possibilities

How will the Open Payments database be helpful in the future? Although the Sunshine Act was ostensibly passed to allow consumers to make more informed healthcare choices, it is likely that the site will have even more value to researchers and policy makers. The degree to which industry payments actually influence medical care has not been resolved because until now there were scant data with which to properly investigate the issue. But researchers will now be able to compare a trove of industry payment data with other databases recently released by CMS, such as detailed disclosures of physicians’ prescribing patterns.

Even before Open Payments, one research group merged the prescribing database with industry payment data aggregated by the investigative journalism organization ProPublica. They found that payments were strongly correlated with increased prescriptions of companies’ products. Such results, if replicated on a larger scale, may well lead to stricter government regulation of financial relations between companies and physicians. Such regulations, in turn, would hopefully lead to more evidence based healthcare and improved patient outcomes. If so, Open Payments will turn out to be an enterprise well worth the effort.

Notes

Cite this as: BMJ 2014;349:g6651

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
  • Provenance and peer review: Commissioned; not externally peer reviewed.

References


Wednesday, October 8, 2014

Payments to Doctors: The Bottom Line


There's a scene in Ghostbusters in which the characters are discussing gun safety.    
"Don't cross the streams."
"Why?"
"It would be bad."
"I'm fuzzy on the whole good/bad thing. What do you mean, 'bad'?" 
"Try to imagine all life as you know it stopping instantaneously and every molecule in your body exploding at the speed of light. Total protonic reversal."
"Right. That's bad. Okay. All right. Important safety tip. Thanks, Egon."

When it comes to the Sunshine Act and the massive database of payments just released, it's fair to say that we're all a little fuzzy on the "good/bad thing." 
 
Part of the problem is that there's too much data and too many categories, all wrapped up in a website that is tough to navigate. It's easy to lose the forest for the trees, but if we climb above the canopy we can begin to some patterns in Open Payments.  

First, let's do an overview of the large categories. CMS recently released this fact sheet explaining what has and has not been published in this first version of the website. (By the way, my sources for most of the figures in this article are ProPublica and the Open Payments website.)
  • The total amount of money that companies paid out to doctors and teaching hospitals from August-December 2013: $4.6 billion.
  • The amount of money that was actually published on the website: $3.5 billion
  • The unpublished money: $1.1 billion. This includes both disputed payments and payments that companies are allowed by law to delay disclosing (mostly payments related to products not yet approved by the FDA). This unpublished money is a lot, but it represents a relatively small number of payments--only 199,000, as opposed to the 4.4 million payments that have been published.
Now let's play a game that I call "good payments/bad payments".
 
A "good" payment is money invested in medical innovation.  
 
A "bad" payment is money paid to doctors to join the marketing team. To be clear, there's nothing wrong with marketing per se, nor is there anything wrong with a company hiring doctors as employees to market products. Once a doctor becomes a company employee, he or she is transparently part of the company's team, and once you're a member of the team, everybody knows you can no longer be objective when you talk about your company's products.

By "bad" payments, I'm talking about money (and meals, gifts etc....) going to doctors who are apparently independent but actually are not. Their day jobs are to treat patients, but they freelance as speakers, consultants, and consumers of catered lunches. They portray themselves as objective arbiters of information, but in fact they are being paid in such a way that they are de facto members of a ghost marketing team. This is why they are such effective marketers. Ads that don't look like ads are the most persuasive ads.
 
If you're willing to accept this moral yardstick, let's start judging payments.  

Mostly good payments: $3 billion
  • Research ($1.5 billion reported in Open Payments). Good because this is what gets us new medicines and devices. Sure, there are bogus studies meant to carve out market share for lousy drugs, but for the most part research is a good thing.
  • Physician ownership ($1 billion). Good because this is money that doctors are getting in return for investing in companies, providing capital that encourages research and development. The $1 billion is a return on an investment in innovation. Do these docs have conflicts of interest? Sure. But they are not being used by companies as ghost-marketers.
  • Royalties and licenses ($302 million). Good because these are rewards for doctors who have invented new medical devices or other products. Yes, companies have at times abused these payments, using them to curry favor with doctors. But on the whole these payments encourage medical innovation.  
  • Consulting fees ($79 million, half of the $158 million reported). Consulting is a tough one to judge. Sometimes consultants help companies decide on what research to pursue (good); other times they are paid to look at ads and help companies market nonsense me-too products that cost the health care system money (bad). So for accounting purposes, I'm assuming a 50/50 split on the good/bad scale, and assigning half to the good bucket and half to the bad.

 
Mostly bad payments: $500 million
  • Promotional speaking ($203 million). Bad because this turns doctors into drug reps. So bad, in fact, that GlaxoSmithKline decided it would end its promotional speakers' bureau program. The practice is now banned by half of all medical schools.
  • Food ($93 million). The fastest way to a doc's prescription pad is through his or her stomach.
  • Travel and lodging ($74 million). Join the marketers, see the world.
  • Education ($27 million). Companies buying textbooks for doctors. Nuff said.
  • Gifts ($19 million). Really??
  • Non-accredited CME ($15 million). Companies teaching doctors=recipe for disinformation, with some exceptions, such as bona fide training on medical devices.
  • Accredited CME ($4.2 million) Companies paying other companies to teach doctors. See above.
  • Consulting fees ($79 million). See my comments under good payments. 

Granted, I've created a pretty simplistic moral universe here. Some of what I called "good" payments are probably sleazy, and some of the "bad" payments are probably legit. But, as a rough approximation:

--86% of companies' spending was mainly good for the public health
--14% was potentially bad for the public health, because it engendered inappropriate conflicts of interest in physicians.  

The question for companies is whether they can all get together and agree to stop throwing bad money after bad.
 

Wednesday, October 1, 2014

I'm Back! Now Let's Talk Sunshine.

Hi readers. Yesterday was my last day at The Pew Charitable Trusts--timed to coincide with the launch of the Open Payments website.

Before commenting on the website, here are some quick impressions about my last 2 1/2 years in Washington: fascinating, sometimes frustrating, often exhilerating, and overall just a great introduction to the arena of politics. Pew is amazing--work there if you can.

But now, let's talk Sunshine.

When I said my goodbyes to you in March of 2012, the Open Payments website was already delayed, and much of my work at Pew was aimed toward preventing that delay from stretching to infinity and beyond.  The site was finally launched yesterday, one year behind schedule--not too bad.

The website is not what most people were originally anticipating. Most of us were expecting a big search box where you could type in your doctor's name. Instead, what we have are downloadable spreadsheets of varying complexity. CMS--the agency in charge of the site--plans to make it more user-friendly within a month or so.

At this point, the best way to begin to peer through that complexity is by going to Propublica's website, where you can benefit from the wisdon of the undisputed guru of physician payment data-mining, Charles Ornstein.

The main headline is that companies have spent $3.5 billion on various "transfers of value" to physicians and teaching hospitals during the last five months of 2013. That sounds like a lot of money. It is. For fun, I did a back-of-the-envelope calculation and determined that companies spent $23 million/day, or roughly $1 million/hour over that period.

But let's not go overboard. Of that $3.5 billion, about $1.45 billion was for research, and roughly $1 billion was equity that physician-investors have in drug or device companies. That leaves about $1 billion in other payments to doctors and teaching hospitals. These are the potentially dubious payments.

So what do we make of these amounts? How do we judge them? Because ultimately, the reason the Sunshine Act was passed in 2010 was that not all drug company payments are morally equivalent. We must look at the data and judge which payments appropriate and which are not. 

Next post, we'll go through each category of business activity listed in the website and start to assign some moral valence to the payments.  

Preview: The Open Payments website makes companies look better than I would have thought. Stay tuned.

Monday, March 19, 2012

Dr. Carlat Goes to Washington To Head Pew Prescription Project

This will be my last Carlat Psychiatry Blog post for a while, as I have recently accepted a new job as the director of the Pew Prescription Project in Washington DC. My main job there will be to pull together a group of experts to review conflict of interest recommendations, and to work with various partner organizations (AMSA, Community Catalyst, and the National Physician's Alliance) to disseminate these recommendations to medical schools and teaching hospitals throughout the U.S.

Because my current job as owner of Carlat Publishing creates its own potential conflict of interest, I am in the process of relinquishing involvement in the company--hiring a new CEO, and placing any profits into an account which I can access only if and when I return to the company. Although I will continue to own Carlat Publishing, I will draw no salary from it, nor will I have any contact with the business in any way. I want to prevent any appearance that I'm joining Pew in order to increase my company's profits from non-industry-sponsored CME activities.

The Carlat Psychiatry Blog lives on in the form of Thought Broadcast, a blog written by psychiatrist Steve Balt, who is the new editor-in-chief of The Carlat Psychiatry Report.

I thank all my devoted blog readers over the years, and I intend to continue writing and blogging about medical conflicts of interest issues and psychiatry--though not in the context of the Carlat "brand."

So it's goodbye for now.

In gratitude,

Daniel Carlat, M.D.

Friday, January 6, 2012

BMJ's Ten Commandments for the Ideal Physician

The British Medical Journal's great blogger Richard Lehman has published the following Ten Commandments for excellent clinical practice. These are great rules of thumb for any savvy health care practitioner--but they do require that wee bit of extra work to truly understand the statistics behind the medical literature. 
(Hat tip to Steve Balt, MD, for sending me the link). 

The New Therapeutics: Ten Commandments
  • Thou shalt treat according to level of risk rather than level of risk factor.
  • Thou shalt exercise caution when adding drugs to existing polypharmacy.
  • Thou shalt consider benefits of drugs as proven only by hard endpoint studies.
  • Thou shalt not bow down to surrogate endpoints, for these are but graven images.
  • Thou shalt not worship Treatment Targets, for these are but the creations of Committees.
  • Thou shalt apply a pinch of salt to Relative Risk Reductions, regardless of P values, for the population of their provenance may bear little relationship to thy daily clientele.
  • Thou shalt honour the Numbers Needed to Treat, for therein rest the clues to patient-relevant information and to treatment costs.
  • Thou shalt not see detailmen, nor covet an Educational Symposium in a luxury setting.
  • Thou shalt share decisions on treatment options with the patient in the light of estimates of the individual’s likely risks and benefits.
  • Honour the elderly patient, for although this is where the greatest levels of risk reside, so do the greatest hazards of many treatments.