Health and Medical News and Resources

General interest items edited by Janice Flahiff

[Repost] Most practice guideline recommendations based on less-than-ideal quality of evidence

Most practice guideline recommendations based on less-than-ideal quality of evidence.

From the 15 January 2014 Mayo Clinic NewsNetwork article by Shelly Plutowski (@rwp01)

ROCHESTER, Minn. — Jan. 15, 2014 — A study published in the January issue of Mayo Clinic Proceedings shows that most clinical practice guidelines for interventional procedures (e.g., bronchoscopy, angioplasty) are based on lower-quality medical evidence and fail to disclose authors’ conflicts of interest.

“Guidelines are meant to create a succinct roadmap for the diagnosis and treatment of medical conditions by analyzing and summarizing the increasingly abundant medical research,” write Joseph Feuerstein, M.D., and colleagues from Beth Israel Deaconess Medical Center. “Guidelines are used as a means to establish a standard of care … However, a guideline’s validity is rooted in its development process.”

Journalists: Sound bites with Dr. Talwalkar are available in the downloads.

In an accompanying editorial, Jayant Talwalkar, M.D., associate medical director of theValue Analysis Program in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, says that the study further illustrates that existing guidelines are highly variable with respect to evidence quality and transparency.

“Most of the current practice guidelines in circulation do not meet criteria that represent trustworthiness as defined by the Institute of Medicine,” Dr. Talwalkar says.

Dr. Talwalkar also points out that more attention needs to be paid to potential conflicts of interest among guideline authors and guideline development panels.

“There is a growing body of literature documenting the existence of one or more potential conflicts of interest reported for authors or members of guideline development panels,” he says. “As a result, the influence of external activities such as consulting or speaking fees, research grant funding and stock ownership has the potential to create significant bias and uncertainty for issued recommendations.”

Dr. Talwalkar notes that up to 80 percent of recommendations from most guidelines are supported by evidence from non-randomized studies or expert consensus opinion, making conflict of interest disclosure crucial.

Dr. Talwalkar says that, in the future, the guideline-writing process must evolve to include more concise and up-to-date recommendations as well as more transparency about the management of potential conflicts of interest.

Read the entire article here

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January 21, 2014 Posted by | health care, Medical and Health Research News | , | 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

Performance Measurement – Converting Practice Guidelines Into Quality Measure

English: California OPA Health Care Quality Re...

 

Excerpts from the 19 December blog item by Ha-Vinh at Health Services Authors

Performance incentives have been recently adopted in France by the national health care insurer to remunerate French Doctors. In Health care, when one can not measure outcomes one measures process. But a good process for an individual patient doesn’t reflect necessarily a good process for the average patient studied by the evidence-based medical research. In a precedent post I presented what the heterogeneity of treatment effect means. In the present post I will try to highlight where stands the fundamental difference between professional guidelines and quality assessment tools of physician practice. Guidelines stem from the average patient. A quality assessment tool assesses the individual patient dealing with the heterogeneity or deviation around the mean value. From now on, given the use of guidelines made by health policy makers to evaluate health care professionals, it becomes a priority goal for searchers to take into account this use when writing their guidelines. For that purpose they should more insist on the heterogeneity of their results and perform sub group analysis across the different risk level of disease to which their studied subjects are exposed. They should accurately determine if their recommendations are applicable to subjects with multiple co morbidities. That is only at this condition that guideline will coincide with a sound balanced quality assessment tool for physician practice…

Read the entire article here

Comment I left at this blog item..

Thank you…it reinforces my beliefs about practice guidelines, emphasis on guidelines!
It is good to measure compliance, and have incentives for performance…
Although generalizations can be made about how to best treat diseases/conditions…at the end of the day…it is people, not diseases/conditions..that are the focus of any good health care system…and heterogeneity of treatment effect is an important facet of treating the whole person, not just the disease/condition..

 

 

December 20, 2011 Posted by | health care | , , , | Leave a comment

   

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