Editor's Choice

Keep politics out of it

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7521.0-h (Published 13 October 2005) Cite this as: BMJ 2005;331:0-h
  1. Fiona Godlee, editor (fgodlee{at}bmj.com)

    Are complementary and alternative medicines cost effective? Patients are increasingly voting with their feet, despite having to pay out of their own pockets, so governments and health plans must decide whether these treatments should be provided alongside conventional health care. The much leaked and now somewhat improved Smallwood report concludes that they should be funded, arguing that they will help patients and save money. In their editorial (p 856) Trevor Thompson and Gene Feder are perplexed about some aspects of the report—in particular the inclusion of asthma as one of the “effectiveness gaps” of conventional medicine. But overall they conclude that complementary medicine should be included in clinical guidelines despite limited evidence of cost effectiveness.

    As an example of how poor the evidence is, Peter Canter and colleagues present a systematic review of cost effectiveness analyses of complementary treatments (p 880). They found only five rigorous analyses, one of acupuncture and four of spinal manipulation. They conclude that these treatments are an additional cost to usual care, with uncertain clinical benefit.

    If the evidence for older medicines remains thin, biotechnology is not faring any better. Recombinant DNA and other techniques were set to provide us with cheaper and better treatments, but Roberta Joppi and colleagues found that few biotech products on the market have been rigorously evaluated (p 895). They reviewed 61 substances licensed by the European Medicines Evaluation Agency. Most turned out to be variations on existing drugs rather than true therapeutic innovations and were generally more expensive than the non-biotech alternatives.

    Meanwhile, a class of drug that had a cloud over it gets a reprieve this week. A BMJ editorial concluded last year that angiotensin receptor blockers were not obviously superior to ACE inhibitors in people at high risk of cardiovascular events and that they may increase the risk of myocardial infarction. This week we publish a systematic review by Michael McDonald and colleagues which finds no evidence of increased risk (p 873). This fits recent trial findings that drugs acting on the renin-angiotensin system provide better control of blood pressure and result in fewer deaths and less diabetes than older antihypertensive regimens (p 859).

    For those trying to decide between one of several treatments, Deborah Caldwell and colleagues show how to do this without relying on indirect comparisons (p 897). However we make these decisions, one thing is clear—politics should not come into it. Frank Davidoff, a former editor of Annals of Internal Medicine, has resigned as an adviser to the US Food and Drug Administration because of the way it postponed a decision on over the counter sales of emergency contraception: “Flagrantly,” he says, “on the basis of political influence rather than scientific and clinical evidence” (p 861). And we should all be concerned that the UK's health secretary, Patricia Hewitt, sees it as within her gift to allow women with breast cancer to be tested for treatment with the new wonder drug trastuzumab (Herceptin) (p 864). Aren't decisions like that what arm's length evaluators like NICE are for?

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