Health and Medical News and Resources

General interest items edited by Janice Flahiff

[Reblog] THE BATTLE OF INTERPRETING RESEARCH RESULTS TO SPECIFIC AUDIENCES

From the 28 April 2015 post at Nordic EBM

Klingons3

Evidence-based medicine has been called “cookbook medicine” by some of its more vocal critics. This implies that evil faceless organisations like Cochrane aim to turn all healthcare workers into mindless automatons who blindly follow dictums derived solely from scientific evidence. I hope it doesn’t surprise many in that this has never been the aim of Cochrane, or EBM in general, nor will it ever be. EBM, or EBP if you prefer the term ‘practice’ rather than the more vague ‘medicine’, is a belief system that rests on three pillars (cf. five in Islam). The EBM pillars are: 1) best available scientific evidence (i.e. the purview of Cochrane and yours truly), 2) clinical experience and 3) patient preferences and values. So, the main gist is that evidence doesn’t matter – no matter how scientific – if we don’t have a clinician at hand to interpret it for the benefit of a particular patient equipped with a particular set of values. For example, in a situation where two very similar patients have the same condition, one might wish to achieve speedy return to work whereas the other might rather avoid pain at all cost. The clinician would then use his or her judgment to identify the best course of treatment for both based on experience and what us science types have to offer. However, let us now leave the two pillars of clinical experience and patient preferences to be explored in future posts so that we can chew the first a bit more.

Now, the evidence bit in EBM is often understood to mean results of systematic reviews(a fancy type of research). Inasmuch as they offer an abstracted truth devoid of context (see my earlier post on mathematical ghosts) they still need to be interpreted for use in particular circumstances. This doesn’t always have to be done for every single patient by every single clinician separately. Think of the usefulness of reinventing the wheel for every drive. Often the thinking behind the interpretation and application of evidence can be written down and made use of by many. On a population level this means drafting guidelines. However, it is important to note that when scientific evidence is freely available one does not need to wait for formal committees to grow their beards long enough to formulate official guidelines. Especially when even supposedly professional guideline developers can do a really poor job (see previous post by Margot Joosen). In fact, all informed people and communities should participate in making sense of and advocating for the use of research to back up health decisions. In the end it affects the quality of care they receive.

May 20, 2015 Posted by | health care | , , , , , , | Leave a comment

Researchers identify 146 contemporary medical practices offering no net benefits

From the 22 July 2013 EurekAlert article
[Please note that I added emphasis to some sentences!]

Study published in Mayo Clinic Proceedings documents reversal of established medical practices in last decade

Rochester, MN — While there is an expectation that newer medical practices improve the standard of care, the history of medicine reveals many instances in which this has not been the case. Reversal of established medical practice occurs when new studies contradict current practice. Reporters may remember hormone replacement therapy as an example of medical reversal. A new analysis published in Mayo Clinic Proceedings documents 146 contemporary medical practices that have subsequently been reversed.

A team of researchers led by Vinay Prasad, MD, Medical Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, reviewed ten years of original articles published in the New England Journal of Medicine testing standard of care.

“The purpose of our investigation was to outline broad trends in medical practice and identify a large number of practices that don’t work,” says Dr. Prasad. “Identifying medical practices that don’t work is necessary because the continued use of such practices wastes resources, jeopardizes patient health, and undermines trust in medicine.”

Dr. Prasad and his investigative team evaluated 1,344 original articles published in the New England Journal of Medicine between 2001 and 2010 that examined a new medical practice or tested an established one. This included assessment of a screening, stratifying, or diagnostic test, a medication, a procedure or surgery, or any change in health care provision systems.

Dr. Prasad and colleagues made several interesting findings. First, only a minority of studies over the last 10 years even tested current medical practices. Dr. Prasad found that only 27% (363/1344) of articles that tested a practice tested an established one. Instead, the vast majority of such studies, 73% (981/1344), tested a new medical practice. Dr. Prasad says, “While the next breakthrough is surely worth pursuing, knowing whether what we are currently doing is right or wrong is equally crucial for sound patient care.”

Dr. Prasad’s major conclusion concerns the 363 articles that test current medical practice — things doctors are doing today. His group determined that 146 (40.2%) found these practices to be ineffective, or medical reversals. Another 138 (38%) reaffirmed the value of current practice, and 79 (21.8%) were inconclusive — unable to render a firm verdict regarding the practice.

Dr. Prasad comments, “A large proportion of current medical practice, 40%, was found to offer no benefits in our survey of 10 years of the New England Journal of Medicine. These 146 practices are medical reversals. They weren’t just practices that once worked, and have now been improved upon; rather, they never worked. They were instituted in error, never helped patients, and have eroded trust in medicine.”

Dr. Prasad adds, “Health care costs now threaten the entire economy. Our investigation suggests that much of what we are doing today simply doesn’t help patients. Eliminating medical reversal may help address the most pressing problem in health care today.”

Key examples of medical reversal include the following:

Stenting for stable coronary artery disease was a multibillion dollar a year industry when it was found to be no better than medical management for most patients with stable coronary artery disease. Hormone therapy for postmenopausal women intended to improve cardiovascular outcomes was found to be worse than no intervention. The routine use of the pulmonary artery catheter in patients in shock was found to be inferior to less invasive management strategies.

Other instances pertain to the use of the drug aprotinin in cardiac surgery, use of a primary rhythm control strategy for patients with atrial fibrillation, use of cyclooxygenase 2 inhibitors, early myringotomy procedures, and application of recommended glycemic targets for patients with diabetes.

Says Dr. Prasad, “To our knowledge, this is the largest and most comprehensive study of medical reversal. The reversals we have identified by no means represent the final word for any of these practices. But, the reversals we have identified, at the very least, call these practices into question.”

In an accompanying editorial, John P. A. Ioannidis, MD, DSc, of the Stanford Prevention Research Center, Department of Medicine and the Department of Health Research and Policy at Stanford University School of Medicine, comments on the work of Prasad and his team and evaluates it within a broader context.

“The 146 medical reversals that they have assembled are, in a sense, examples of success stories that can inspire the astute clinician and clinical investigator to challenge the status quo and realize that doing less is more,” notes Dr. Ioannidis. “If we learn from them, these seemingly disappointing results may be extremely helpful in curtailing harms to patients and cost to the health care system.”

According to Dr. Ioannidis, it is just as important to promote and disseminate knowledge about ineffective practices that should be reversed and abandoned. Given the widespread attention that practice guidelines typically receive, particularly when published by authoritative individuals or groups, he questions whether a generally higher level of evidence should be required before these guidelines are recommended and can impact clinical practice.

“Finally, are there incentives and anything else we can do to promote testing of seemingly established practices and identification of more practices that need to be abandoned? Obviously, such an undertaking will require commitment to a rigorous clinical research agenda in a time of restricted budgets,” concludes Dr. Ioannidis. “However, it is clear that carefully designed trials on expensive practices may have a very favorable value of information, and they would be excellent investments toward curtailing the irrational cost of ineffective health care.”

July 22, 2013 Posted by | health care | , , , , , , , , | Leave a comment

UK Centre for Reviews and Dissemination (CRD) announces new partnership with PubMed Health

https://i1.wp.com/www.nlm.nih.gov/pubs/techbull/so11/graphics/pm_health_fig1.gifCRD announces new partnership with PubMed Health.

From the 9 December press release (at Eureka News Alert)CRD announces new partnership with PubMed Health

A new partnership between the Centre for Reviews and Dissemination (CRD) at the University of York and PubMed Health is launched today.

PubMed Health is a new online service provided by the National Center for Biotechnology Information (NCBI) at the US National Library of Medicine (NLM) – the world’s largest medical library. The service provides summaries and full text of selected systematic reviews and also provides information for consumers and clinicians based on those reviews

Systematic reviews are widely recognised as reliable sources of information about the effects of healthcare interventions. But as with individual research studies, they can be hard to find, may have flaws and can be difficult to interpret.

Since 1994, CRD has been producing and maintaining DARE, a database which uniquely provides access to over 11,000 abstracts of quality assessed and critically appraised systematic reviews. The database has become a key resource for health professionals and policy makers as it provides its users with a ‘bottom line’ on the overall validity and reliability of each review.

The new partnership involves CRD providing DARE content to PubMed Health.

Deputy Director of CRD Dr Amanda Sowden said: “CRD aims to produce and disseminate high quality evidence to inform health care decision making in the UK and internationally. Our partnership with PubMed Health is an exciting and prestigious development that will help give our database content truly global reach.”

 

—————

and…from the NLM (US National Library of Medicine’s December Technical Bulletin)

Update — PubMed Health December 2011 Release

With its December release, PubMed® Health grows to over 18,000 systematic reviews and health technology assessments in the last 10 years. With the inclusion of the Database of Reviews of Effects (DARE) from the Centre for Reviews and Dissemination in England, PubMed Health is getting close to comprehensive coverage of reliable systematic reviews on clinical effectiveness.

Other new features and content additions in this release include:

  • Evidence-based, regularly updated information on cancer for consumers and health professionals from the National Cancer Institute (NCI®) Physician Data Query (PDQ®) database.
  • Two full-text books under “Understanding research results” from the “Understand clinical effectiveness” tab:
    Irwig L, et al. Smart Health Choices: Making Sense of Health Advice. London: Hammersmith Press; 2008. Available from: http://www.ncbi.nlm.nih.gov/books/NBK63638/

    Evans I, et al. Testing Treatments: Better Research for Better Healthcare. 2nd edition. London: Pinter & Martin; 2011. Available from: http://www.ncbi.nlm.nih.gov/books/NBK66204/
  • Simplified and broadened — display of medical encyclopedia search results.

Addition of Over 12,000 Reviews from DARE

A new section in the “Contents” drop-down box on the homepage has been added for the DARE reviews (see Figure 1). This new content type rounds out PubMed Health’s coverage of systematic reviews on clinical effectiveness in the published biomedical literature, joining over 4,500 Cochrane reviews and hundreds of systematic reviews by health technology assessment agencies.

Screen capture of Contents drop-down box
Figure 1: Contents drop-down box.

DARE is a key database produced by the Centre for Reviews and Dissemination (CRD) and funded by England’s National Institute of Health Research. Information specialists at CRD regularly search an extensive group of electronic databases, supplemented by hand searching, to identify published systematic reviews that meet their set of scientific criteria.

For about half of the reviews that qualify for DARE, a CRD summary with critical appraisal of the scientific quality of the review is added. These may raise caveats about the reliability of the review, as in the example featured in Figure 2.

PubMed Health displays the title of the review and its citation (see #1 in Figure 2). For those reviews with a full CRD summary and appraisal, the conclusion is then displayed, followed by a link to the complete version (see #2 in Figure 2). This is followed by the abstract of the review itself, if one is included in PubMed (see #3 in Figure 2).

Screen capture of Example of a DARE review with CRD summary
Figure 2: Example of a DARE review with CRD summary.

Each PubMed Health record from DARE includes a link to an explanation of CRD’s process and assessment criteria.

Currently, DARE is added to weekly, and new records and summaries will appear shortly afterward in PubMed®Health. The records will not yet appear in PubMed.

Changes to Display of Search Results

DARE reviews are returned with all results, and can also be viewed under their own content type (see #1 in Figure 3).

Medical encyclopedia content has been simplified, with some content text also appearing (see #2 in Figure 3). Previously, only medical encyclopedia content for diseases and drugs were shown on the search results page. Relevant medical encyclopedia content for procedures and other types of searches now display.

The parallel “Clinical Queries” filter search for systematic reviews in PubMed remains (see #3 in Figure 3). This search continues to return results chronologically.

Screen capture of Search results
Figure 3: Search results.

NCI cancer information for patients and health professionals appears under the “For consumers” and “Clinical Guides” links, respectively.

Twitter followers can learn more about PubMed Health content and additions by following @PubMedHealth.

By Hilda Bastian
National Center for Biotechnology and Information

December 10, 2011 Posted by | Educational Resources (High School/Early College(, Finding Aids/Directories, Health Education (General Public), Librarian Resources, Professional Health Care Resources | , , , , , | Leave a comment

   

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