Doctors call for evidence-based appropriateness criteria for elective procedures

From the 26 December 2012 EurkAlert article

In New England Journal of Medicine, Weill Cornell researchers advocate the development and implementation of criteria for elective procedures, with joint replacement surgery as an example

Many of the most common inpatient surgeries in the United States are performed electively. These surgeries are expected to significantly increase with the enactment of the Affordable Care Act. In a new perspectives article, published in the Dec. 27 edition of The New England Journal of Medicine, a team of Weill Cornell Medical College researchers are recommending the nation’s health care leaders and medical community join forces to establish evidence-based appropriateness criteria to determine which patients are most in need of elective procedures, such as joint replacement surgery, to slow the projected surge in demand and rising costs. Currently, there are no appropriateness criteria for most of the common elective procedures.

Total joint replacement surgeries — such as hip and knee replacements — are among the most common inpatient surgeries in the United States and are used as a prime example of elective surgeries that could benefit from implementing appropriateness criteria. Patients requesting joint replacement surgery vary from those disabled by their joint arthritis to those who do so to maintain an active lifestyle without pain. Total joint replacement surgeries are expected to quadruple over the next two decades in the United States, contributing to the rise in health care costs and increasing the risk of medical complications.

“The purpose behind establishing criteria is to use evidence-based metrics to prioritize patients most in need,” says lead author Dr. Hassan M.K. Ghomrawi, assistant professor of public health at Weill Cornell and an outcomes research scientist at Hospital for Special Surgery. “We don’t want to sacrifice necessary care when thinking of cost-containment.”..

..

Current cost-containment proposals focus primarily on payment reforms, such as pay-for-performance and bundled payments. But in their perspective, titled “Appropriateness Criteria and Elective Procedures — Total Joint Arthroplasty,” the authors posit that developing and implementing evidence-supported criteria that identifies the appropriate patients who are most likely to benefit from surgery will also slow the growing costs of these procedures.

“Identifying patients who are likely to benefit the most from these procedures could help to combat increasing health care costs while enhancing access and quality,” says senior author Dr. Alvin I. Mushlin,…

Read the entire article here

Related articles

• Doctors call for evidence-based appropriateness criteria for elective procedures (medicalxpress.com)
• Contrary To Common Assumption, The Obese Achieve Great Outcomes From Joint Replacement Surgery (medicalnewstoday.com)
• Clots Following Joint Replacement Surgery Prevented By Aspirin (medicalnewstoday.com)
• Complications challenge rheumatoid arthritis patients after joint replacement surgery (eurekalert.org)
• Decision Aids Lower the Rate of Elective Surgery (labsoftnews.typepad.com)

NIH Launches Web Resource on Complementary and Alternative Medicine

From the US National Institutes of Health (NIH) press release

A new online resource, designed to give health care providers easy access to evidence-based information on complementary and alternative medicine (CAM), was unveiled today by the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health.

With this new resource, providers will have the tools necessary to learn about the various CAM practices and products and be better able to discuss the safety and effectiveness of complementary and alternative medicine with their patients….

…NCCAM developed a resource that provides reliable, objective, and evidenced-based information on CAM, including:

• links to relevant clinical practice guidelines
• safety and effectiveness information
• links to systematic reviews
• summaries of research studies
• scientific literature searches
• programs for continuing education credit
• patient fact sheets
• NCCAM’s Time to Talk tool kit on communicating about CAM.

Americans annually spend nearly $34 billion out-of-pocket on CAM products and practices. Surveys show that nearly 40 percent of American adults and 12 percent of American children use some form of CAM. Other surveys show that patients do not regularly discuss these practices with their health care providers. In fact, a recent study of Americans aged 50 and older found that overall two-thirds of respondents had not discussed CAM with their health care provider.

“NCCAM is charged to study and provide evidence-based information on the safety and efficacy of CAM health practices that are readily available and already used by a great number of people,” said Josephine P. Briggs, M.D., director of NCCAM. “As a physician, I understand the need to have easily accessible and accurate information on all health practices. This Web resource is a way for NCCAM to share this valuable information with all providers.”

To use this resource, please visit nccam.nih.gov/health/providers/.

NCCAM’s Time to Talk campaign encourages patients to tell their providers about CAM use and providers to ask about it by offering tools and resources—such as wallet cards, posters, and tip sheets—all of which are available for free at nccam.nih.gov/timetotalk/.

The mission of the National Center for Complementary and Alternative Medicine (NCCAM) is to define, through rigorous scientific investigation, the usefulness and safety of complementary and alternative medicine (CAM) interventions and their roles in improving health and health care. For additional information, call NCCAM’s Clearinghouse toll free at 1-888-644-6226, or visit the NCCAM Web site at nccam.nih.gov.

The National Institutes of Health (NIH)—The Nation’s Medical Research Agency—includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical, and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit http://www.nih.gov.

Additional Resources

Natural & Alternative Treatments
Contains detailed information on almost 200 different conditions and the conventional and natural treatments used to treat them, over 300 herbs and supplements, plus drug-herb and drug-supplement interactions for more than 90 drug categories.

Drugs and Supplements (sponsored by the Mayo Clinic)

Somewhat lengthy drug and over-the-counter medicationinformation with these sections: description, before using, proper use, precautions and side effects. From Micromedex, a trusted source of healthcare information for health professionals.  

Herb and supplement information includes information on uses based on scientific evidence as well as safety and potential interactions with drugs, herbs, and supplements. From Natural Standard, an independent group of researchers and clinicians

Drugs, Supplements, and Herbal Information (from a MedlinePlus page)

Prescription and over-the-counter medication information contains answers to many general questions including topics as what a drug is used for, precautions, side effects, dietary instructions, and overdoses. From the American Society of Health System Pharmacists

Herb and supplement information includes information on uses based on scientific evidence as well as safety and potential interactions with drugs, herbs, and supplements. From Natural Standard, an independent group of researchers and clinicians.

Related Articles

• Let’s do some real science for a change! The NCCAM Strategic Plan 2011-2015 (scienceblogs.com)
• Herbal Medicines: ‘Natural’ Doesn’t Always Mean Safe, Says Royal Pharmaceutical Society (medicalnewstoday.com)
• Health-Care Providers Are Prescribing Nontraditional Medicine (Medical News Today, 10 May 2011)
• Integrative medicine, spirituality improves outcomes in urban adolescents with asthma (eurekalert.org)
• Audio File About the NCCAM Health Care Provider  Portal (NCAAM) 
• Study Questions Giving Babies Botanical Supplements, Teas (jflahiff.wordpress.com)

Disaster Medicine and Public Health Preparedness (Journal Article)

From the March 18 2011 DISASTR-OUTREACH-LIB **posting

Disaster Medicine and Public Health Preparedness
The March 2011 issue of this journal includes an article titled,
“Supporting Evidence-based Health Care in Crises: What Information Do Humanitarian Organizations Need?” ***as well as a selection of open access articles relevant to the Japan earthquake. [Submitted by Anna Gieschen]

Abstract

Supporting Evidence-based Health Care in Crises

What Information Do Humanitarian Organizations Need?

Tari Turner, PhD, Sally Green, PhD and Claire Harris, MBBSAuthor Affiliations: Dr Turner and Dr Green are with the Australasian Cochrane Centre, Monash University, Victoria, Australia; and Dr Harris is with the Centre for Clinical Effectiveness, Southern Health, Victoria, Australia.

In crisis situations, there is an enormous burden of disease and very limited resources. To achieve the best possible health outcomes in these situations and ensure that scarce resources are not wasted, knowledge from health research needs to be translated into practice. We investigated what information from health research was needed by humanitarian aid workers in crisis settings and how it could be best provided. Semistructured interviews were conducted by telephone with 19 humanitarian aid workers from a range of organizations around the world and the results analyzed thematically. Participants identified a clear and currently unmet need for access to high-quality health research to support evidence-based practice in crisis situations. They emphasized that research into delivery of health care was potentially morevaluable than research into the effectiveness of particular clinical interventions and highlighted the importance of includingcontextual information to enable the relevance of the research to be assessed. They suggested that providers of health research information and humanitarian aid organizations work together to develop these resources. [editor Flahiff’s emphasis]

**DISASTR-OUTREACH-LIB is a discussion group for librarians, information specialists and othersinterested in disaster information outreach to their communities and responding to information needs for all-hazards preparedness, response and recovery.
The DISASTR-OUTREACH-LIB archives are available at
https://list.nih.gov/archives/disastr-outreach-lib.html.

*** For information on how to get this article for free or at low cost, click here

Related Articles

• U.S. Unprepared for Major Radiation Emergency: Survey (jflahiff.wordpress.com)
• Emergency mental health lessons learned from Continental Flight 3407 disaster (scienceblog.com)
• Disaster Preparedness: Is Your Family Ready? (abcnews.go.com)
• Japan earthquake – disaster relief information sources (openmedicine.ca)
• Japan’s Disaster and the Limits of Self-Sufficiency (scienceblogs.com)
• Health care needs public acceptance of evidence based medicine (kevinmd.com)

Promise of genomics research needs a realistic view

Promise of genomics research needs a realistic view

This is James P. Evans, M.D., Ph.D., of the University of North Carolina at Chapel Hill.

From the February 17, 2011 Eureka news alert

In the ten years since the human genetic code was mapped, expectations among scientists, health care industry, policy makers, and the public have remained high concerning the promise of genomics research for improving health.

But a new commentary by four internationally prominent genetic medicine and bioethics experts cautions against the dangers of inflated expectations – an unsustainable genomic bubble – and it offers ways to avoid it while still realizing “the true – and considerable – promise of the genomic revolution.”

“This commentary is an attempt to bring some balance to the hopes and claims that swirl around the issue of genomic medicine. It is a cautionary essay that tries to extol the real and formidable potential of genomic medicine but also attempts to counter what we see as exaggerated claims, said lead author medical geneticist James P. Evans, MD, PhD, Bryson Distinguished Professor of Genetics and Medicine at the University of North Carolina at Chapel Hill and the UNC Lineberger Comprehensive Cancer Center.

“Our fear is that if we are uncritical and naïve in our enthusiasm for these exciting technologies we risk both diversion of precious resources and premature implementation which could hurt patients – as well as a backlash which will hurt our field,” Evans warns.

The commentary appears in the February 18, 2011 issue of the journal Science. Co-authors with Evans are Eric M. Meslin, PhD, director, Center for Bioethics, Indiana University, Indianapolis; Theresa M. Marteau, PhD, FMedSci, professor of health psychology, Kings College, London, UK; and Timothy Caulfield, LL.M., F.R.S.C., Canada Research Chair in Health Law & Policy, University of Alberta, Edmonton, Alberta.

“Breathtaking” is how the authors describe the progress already made in genomic research. But, they caution, the considerable promise of genomics must be evaluated through a realistic lens. Advances in individualized medicine, or pharmacogenetics for example, still require the importance of human behavior in health outcomes: the most powerful predictor of a drug’s efficacy depends less on genetics than whether the patient takes the drug.

Among the reasons they cite making genomics the persistent recipient of “hyperbole” and inflated expectations, some are tied to impatience for practical applications, market forces and unbridled (but uncritical) enthusiasm. The news media also is named for “playing an obvious role in the creation of unrealistic hopes.”

“These forces act together to produce a kind of “cycle of hype” that drive overly optimistic representations of the research,” said co-author Timothy Caulfield.

In their short-list of recommendations for avoiding inflation of the “genomic bubble, Evans and co-authors offer the following: (1) reevaluate funding priorities to stress behavioral and social science research aimed at behavior change for improving health; (2) foster a realistic understanding “of the incremental nature of science and the need for statistical rigor,” within the scientific community and that the media make more responsible claims for genomic research; (3) maintain a focus on developing high-quality evidence before integrating good ideas into medical practice.

“By highlighting the risks of continuing to promise results from genomic science, we were hoping to draw attention to a more sustainable approach to reaping the benefits from genomic science,” said co-author Eric Meslin.

The authors assert their belief that the current age of genomics will provide great benefits to human health “Ours is not a call to gut existing research or too-rigidly tie funding to degree of disease burden … The pursuit of our common goal – improved human health – demands that we take a hard look at disease causation and order our priorities accordingly.”

 

Related Web sites and articles

The Genomic Revolution (exhibit by the American Museum of Natural History) is an online Web site with videos

(US) Human Genome Project Information

The Genomic Revolution: Unveiling the Unity of Life [online book]

Genome Revolution FOCUS (a Duke University Library Guide)

Genomic Links (online resources for professionals, teachers, and all)

 

 

 

New Chapters for Effective Health Care Program’s Methods Guide for Comparative Effectiveness Reviews

New Chapters for Effective Health Care Program’s Methods Guide for Comparative Effectiveness Reviews

The Agency for Healthcare Research and Quality (AHRQ) ’s Effective Health Care Program has released two new chapters of the Methods Guide for Effectiveness and Comparative Effectiveness Reviews:

·         “Finding Evidence for Comparing Medical Interventions”

·         “Assessing the Applicability of Studies When Comparing Medical Interventions”

To learn more about the Methods Guide for Effectiveness and Comparative Effectiveness Reviews and to access other chapters in this guide.

Cochrane Reviews – A Great Source for Sound Medical Evidence

Cochrane Reviews are thorough unbiased detailed systematic reviews of research in both human health care and health policy.

Some Cochrane Reviews investigate whether or not an intervention (as an antibiotic) really produces a specific intended effect (as reducing sore throat symptoms).

Other Cochrane Reviews look for evidence that a diagnostic test is accurate for a given disease within a specific patient group.

Evidence is largely based on clinical trials.

All Cochane Reviews address specific narrowly defined questions. Each review is the product of a independent team of health care and information professionals (as librarians). These scientific reviews are the result of many hours of analyzing original research. Each review can take up to two years to publish.

While there are presently over 4000 Cochrane Reviews, the Review collection does not cover every possible intervention, drug, or diagnostic test.

However, the abstracts of all reviews are available to the public. Many have plain language summaries.

(For suggestions on how to get free full text of Cochrane Reviews, please click here).

How to search for Cochrane Reviews

**Go to Cochrane Reviews- Explore

**Search for reviews using the simple search at the page or the advanced search option.

The Cochrane Review Home page contains informational links, including

**The Top 50 reviews (Past 24 hours, 7 days, and 30 days)

**Special Collections from the Cochrane Library

**Cochrane Library Editorials

Related Articles

• Poorly presented risk statistics could misinform health decisions (jflahiff.wordpress.com)
• How Should Systematic Reviews Consider Evidence On Harms? (Medical News Today, May 3, 2011)

Should we be teaching information management instead of evidence-based medicine?

From the full text article at the publisher’s Web site

[via a Medlib-L posting on November 29, 2010 by Julie Esparza, Clinical Medical Librarian, LSU]

Shepard R. Hurwitz1 and David C. Slawson2

(1) Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC 27599-7055, USA
(2) University of Virginia School of Medicine, Charlottesville, VA, USA

Shepard R. Hurwitz
Email: shurwitz@abos.org
Published online: 22 May 2010

Abstract
Background
To encourage high-quality patient care guided by the best evidence, many medical schools and residencies are teaching techniques for critically evaluating the medical literature. While a large step forward in many regards, these skills of evidence-based medicine are necessary but not sufficient for the practice of contemporary medicine and surgery. Incorporating the best evidence into the real world of busy clinical practice requires the applied science of information management. Clinicians must learn the techniques and skills to focus on finding, evaluating, and using information at the point of care. This information must be both relevant to themselves and their patients and be valid.
Where are we now?
Today, orthopaedic surgery is in the post-Flexner era of passive didactic learning combined with the practical experience of surgery as taught by supervising experts. The medical student and house officer fill their memory with mountains of facts and classic references ‘just in case’ that information is needed. With libraries and now internet repositories of orthopaedic information, all orthopaedic knowledge can be readily accessed without having to store much in one’s memory. Evidence is often trumped by the opinion of a teacher or expert in the field.
Where do we need to go?
To improve the quality of orthopaedic surgery there should be application of the best evidence, changing practice where needed when evidence is available. To apply evidence, the evidence has to find a way into practice without the long pipeline of change that now exists. Evidence should trump opinion and unfounded practices.
How do we get there?
To create a curriculum and learning space for information management requires effort on the part of medical schools, residency programs and health systems. Internet sources need to be created that have the readily available evidence-based answers to patient issues so surgeons do not need to spend all the time necessary to research the questions on their own. Information management is built on a platform created by EBM but saves the surgeon time and improves accuracy by having experts validate the evidence and make it easily available.
Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Dr. Slawson is a paid consultant for Wiley & Son publisher.

Wrapped in Data and Diplomas, It’s Still Snake Oil (NY Times Book Review – “Bad Science”)

Excerpt from the book review by Katherine Boutin (NY Times, Nov 1)

Ben Goldacre*** is exasperated. He’s not exactly angry — that would be much less fun to read — except in certain circumstances. He is irked, vexed, bugged, ticked off at the sometimes inadvertent (because of stupidity) but more often deliberate deceptions perpetrated in the name of science. And he wants you, the reader, to share his feelings.

Goldacre’s targets include

• overpriced beauty and spa treatments
  (for example, Vaseline moisturizes just as well as Almont Cellular DNA Complex (made from “specially treated salmon roe DNA”))
• diets, dietary supplements, and vitamin regimes that are not based on solid scientific evidence
• “diploma mills” (where even his cat could get a degree)

Goldacre does teach in this book

• the importance of evidence-based medicine
  (“Studies show” is not good enough, he writes: “The plural of ‘anecdote’ is not data.”)
• how to weigh evidence through the funnel plot, meta-analysis, and the Cochrane collection**
• how to  critically read claims through statistics related questions as who is being tested? what is the control group?

The book is available online at http://us.macmillan.com/badscience

BAD SCIENCE Quacks, Hacks, and Big Pharma Flacks.By Ben Goldacre. Faber and Faber. 288pages. $15.

——————————————————-

*Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values. (Sackett DL, Straus SE, Richardson WS, et al. Evidence-based medicine: how to practice and teach EBM. 2nd ed. Edinburgh: Churchill Livingstone, 2000.) Click here for a medical library guide on evidence based medicine.

**The Cochrane collection is a fee (subscription) based collection of systematic reviews (where scientific evidence on specific medical questions (as does Vitamin X help with Condition Y) is gathered and analyzed for effectiveness).
It is available to the public at some medical and hospital libraries. Call ahead and ask for a reference librarian.

Want to learn more about statistics but don’t have the time to take a course? Ask a reference librarian at any library for book and Web site recommendations.  Or email me at jmflahiff@yahoo.com.

***Ben Goldacre is a writer, broadcaster, and doctor best known for the Bad Science column in The Guardian. Trained in Oxford and London, with brief forays into academia, Goldacre works full-time for the National Health Service.  He has a blog, badscience.net