I brought a pile of recent medical journal articles with me to read on my long flight to San Diego where we were headed for a winter vacation. Journal articles usually recommend new tests and treatments, but I was struck by three articles from different well-respected journals that all recommended doing less. I found this to be quite extraordinary. The change may reflect a new willingness to question overly aggressive treatments promoted by the drug industry.
The first article, from the New England Journal of Medicine, discussed how the frequency of Pap smears could be extended to once every five years by including a test for the human papilloma virus (HPV). If the HPV test is negative and the Pap smear is normal—which is what occurs in about 92 percent of cases—a repeat screening isn’t required for another five years. And screenings can be discontinued completely for women over 65 who have had normal Pap smears previously.
The second article, from JAMA Internal Medicine (formerly the Archives of Internal Medicine), described how large numbers of patients with diabetes in the Veterans Health Administration were being over treated with drugs, thus putting them at risk for low-blood-sugar reactions. Low blood sugar can kill brain cells, cause falls, and rarely can even lead to death. The authors urged that patients with diabetes who are 75 years old and older or who have cognitive impairment, kidney disease, or other high-risk conditions should not be treated as aggressively as younger, healthier patients with drugs that lower blood sugar.
The third article was from JAMA and published the long-awaited eighth report from the Joint National Committee (JNC-8) on the treatment of high blood pressure. The committee changed the target goal for blood pressure from 140/90 to 150/90 for persons 60 years of age and older. They also recommended that patients with diabetes have a slightly higher target blood pressure, namely 140/90, rather than the previous target of 130/80. The committee relaxed these blood pressure target goals based on a lack of convincing evidence that the more stringent goals led to less death or disability.
The process that the Committee followed in coming up with their guidelines differed in a noteworthy way from previous reports—committee members with conflicts of interest with the pharmaceutical industry had to recuse themselves from voting on the recommendations. Four of the 17 (24 percent) members of the panel had relationships with industry. In contrast, 9 of the 11 (82 percent) lead authors of the JNC-7 report were paid speakers or advisors to drug companies, and all of them were allowed to vote on the recommendations.
While we can’t say for sure that the hypertension changes reflect a diminished influence of drug companies on the Committee’s processes, that may be the case.The new guidelines recommended by JNC-8 will likely mean fewer people will be treated for hypertension. In addition, these new guidelines may mean that generic drugs could assume a more prominent role in the future treatment of hypertension as well, since the target blood pressure will be easier to achieve with a single drug and the recommended first-line drugs are all available as low-cost generics.
The overtreatment of diabetes may also have been driven by high-pressure tactics of drug companies to convince doctors to treat all patients with diabetes aggressively (especially with newer, expensive drugs) regardless of the age of the patient or other risk factors.
Those who profit from overtreatment—drug companies, laboratories, and physicians—benefit when the public comes to believe that overtreatment is standard treatment. For instance, most of my female patients still believe they should be getting a Pap smear every year.
Implementing the new recommendations in the three articles will require efforts to educate the general public that this is the right thing to do. Given our corporate-driven American culture in which more is better, it will be challenging to convince people that, in many cases, less is best.
Stephen R. Smith, M.D., M.P.H., Community Catalyst physician consultant