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Cochrane Collaboration, High Court of Evidence-Based Medicine, Blasted for Bias in Medscape PDF Print E-mail
Written by John Weeks   
Friday, 22 June 2007

Clay Feet:  Cochrane Collaboration, High Court of Evidence-Based Medicine, Blasted for Economic Bias in Medscape General Medicine

Summary: A recent commentary in Medscape General Medicine suggests that when author Dan Brown gets tired of pulling veils off of the Vatican he might spend a little time unwinding the political-economic machinations that shape what the Cochane Collaboration sees fit to publish. The commentary, by physician-author David Cundiff, MD, is entitled "Evidence-based medicine and the Cochrane Collaboration on Trial." Cundiff concludes: "While evidence-based medicine is absolutely essential to comprehensive healthcare reform, it has been profoundly corrupted by money."

Those who believe that there is a just god called Evidence which arbitrates what is in and what is out of the mainstream of the US healthcare economy may well find themselves in a crisis of faith if they stumble upon a commentary just published in Medscape General Medicine.

Image
Cochrane logo
The commentary is entitled, "Evidence-Based Medicine and the Cochrane Collaboration on Trial"
. The Cochrane Collaboration, known for its systematic reviews of therapies and tests, has reigned over the evidence kingdom for the last 15 years. A positive Cochrane review can be worth tens of millions to a company involved with a therapy, test or procedure. A negative review can send stock prices south.

The Medscape commentary was written by a physician, David Cundiff, MD who volunteered to participate in a Cochrane review of the evidence base for the use of anticoagulants such as warfarin/Coumadin and heparins for blood clots in the lung and leg. Cundiff disclosed that his interest was to a malpractice case against him related to a leg clot (deep vein thrombosis) which had led to the loss of his license. In a review of over 1000 studies typically cited, Cundiff found only one that he gauged to have included proper control subjects. Cochrane later dug up two others which included good controls. He writes:
"Summing the results of the 3 trials, 66 DVT (deep vein thrombosis) patients received anticoagulants and 6 of them died; 60 DVT patients did not receive anticoagulants, and 1 of them died. None of the 3 trials had been referenced in any journal articles or reviews of anticoagulant therapy that I read."
Image
David Cundliff, MD
Cundiff then tells a story that this apparent cover-up of evidence by other reviewers continued inside Cochrane. He suggests that Cochrane's editors made a series of decisions which systematically protected the drugs in the marketplace.
He states that "the Cochrane peer reviewers (at least 4 out of 7 of which had undisclosed financial ties to the drug companies that make anticoagulants) delayed four years over releasing this review for publication."

According to Cundiff, the review ultimately published by the
Cochrane Database of Systematic Reviews was "completely altered by the peer reviewers and editor." He protested to an internal Cochrane appeals process. He is frustrated with how slow Cochrane has been to take up the issue, now nine months without resolution. Cundiff then registered his objections with the FDA. FDA officials also chose to take no action. Cundiff's commentary asks readers to call on the FDA to investigate the safety and efficacy of anticoagulants in treatment of clots in the legs and lungs. Cundiff's conclusion, based on the experience, follows:
"While evidence-based medicine is absolutely essential to comprehensive healthcare reform, it has been profoundly corrupted by money."
Cundiff credits former editor of the Journal of the American Medical Association and now of Medscape General Medicine chief George Lundberg, MD, for choosing to feature this piece. The commentary was recently referenced in an Integrity in Science article posted by the Center for Science in the Public Interest. http://www.cspinet.org/integrity/watch/index.html#3

Image Comment: I wrote Cundiff a note, merely to thank him for his courage in telling the story. Clearly, the man burned more bridges here than the US military in an average Iraq arrival. Cundiff got my note and called me up. I discovered in him a physician-reformer whose critique of the way money influences care decisions goes back to his days as a hospice pioneer. In Cundiff's account, his former hospital wasn't that interested in keeping people out of hospitals. It harmed their business model. Nor was his hospital pleased when Cundiff wrote in an op-ed piece that a new, 900-bed hospital wasn't necessary given the excess of hospital beds in his community.

Cundiff has penned a book entitled Money Driven Medicine: Tests and Treatments that Don't Work.
  In the book, he estimates that roughly $1-trillion of the $2.3-trillion US healthcare tab could be avoided, and 75,000 unnecessary deaths, if mainstream medicine avoided practices which were not supported by evidence. The powerpoint on his website details his case.

Cundiff is also promoting a health reform approach he calls Doctor Managed Care  which he believes would erect a barrier against the over-performance of unnecessary and unproven practices. Cundiff's reform model focuses on empowering primary care physicians and lowering their patient panels roughly 60 percent to 1,000, thus giving them the opportunity to have more time with patients. The Integrator suggested to Cundiff that he consider some primary care physician retooling as part of his reform package so they might be equipped with the best mind-body and natural healthcare tools. This way they can make the most of the extra time with patients, and have more strategies for keeping people out of the sicker care system. And how about non-MD primary care? I sent him the outcomes of the non-pharmacological approach to primary care recently covered in the Integrator and now published n the Journal of Manipulative and Physiological Therapeutics.

Credit Medscape editor Lundberg for choosing to feature Cundiff's piece as well an earlier review by Cundiff on anti-coagulant treatment of leg and lung costs.
Those with long memories will know that when Lundberg was relieved of his JAMA duties nearly a decade ago, one reason given in the media was his decision to devote an entire issue of JAMA, in November 1998, to complementary and alternative medicine. Lundberg's knows something about burning bridges. His revelation of the public interest in CAM helped burn a career which spanned from 1982 to 1999 for him.

That Cundiff is retired offers an idea which Cochrane might consider to remove some, at least, of its built-in potential for bias.  Perhaps only physicians who are retired should be allowed to participate in Cochrane's reviews. (Thanks to James Winterstein, DC, for bringing this article to my attention.)

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Last Updated ( Monday, 23 July 2007 )
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