NYT Evidence Based Medicine Op-Ed

[qwints]

I really don't know what to make of this.
Kerry-Gingrich Op Ed (http://www.nytimes.com/2008/10/24/opinion/24beane.html)

[Skeptic Ginger]

Kind of strange in that it seems to be appealing to the medical community when the appeal needs to be to the public, IMO.Evidence-based health care would not strip doctors of their decision-making authority nor replace their expertise. Instead, data and evidence should complement a lifetime of experience, so that doctors can deliver the best quality care at the lowest possible cost.

Working closely with doctors, the federal government and the private sector should create a new institute for evidence-based medicine. This institute would conduct new studies and systematically review the existing medical literature to help inform our nation’s over-stretched medical providers.

It's like the authors are unaware that EVB has been a trend from quite some time.

I like the idea of comparing the level of science used in sports. I often comment that the level of science used in marketing is quite high as well. We always need more research in medicine. But at the same time, there is a lot of research going on.

[Jeff Corey]

This illustrates one of the problems
1982
Australian physicians Robin Warren and Barry Marshall first identify the link between Helicobacter pylori (H. pylori) and ulcers, concluding that the bacterium, not stress or diet, causes ulcers. The medical community is slow to accept their findings.

1994
A National Institutes of Health Consensus Development Conference concludes that there is a strong association between H. pylori and ulcer disease, and recommends that ulcer patients with H. pylori infection be treated with antibiotics.

1995
Data show that about 75 percent of ulcer patients are still treated primarily with antisecretory medications, and only 5 percent receive antibiotic therapy. Consumer research by the American Digestive Health Foundation finds that nearly 90 percent of ulcer sufferers are unaware that H. pylori causes ulcers. In fact, nearly 90 percent of those with ulcers blame their ulcers on stress or worry, and 60 percent point to diet.

From the CDC website.

[Eos of the Eons]

From the article:
Studies have shownthat most health care is not based on clinical studies of what works best and what does not — be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition. :confused:

Is he talking NDs? This is not true for MDs. What studies? What did they study? Integrated sCAM hospitals?

[Eos of the Eons]

This illustrates one of the problems
1982
Australian physicians Robin Warren and Barry Marshall first identify the link between Helicobacter pylori (H. pylori) and ulcers, concluding that the bacterium, not stress or diet, causes ulcers. The medical community is slow to accept their findings.

1994
A National Institutes of Health Consensus Development Conference concludes that there is a strong association between H. pylori and ulcer disease, and recommends that ulcer patients with H. pylori infection be treated with antibiotics.

1995
Data show that about 75 percent of ulcer patients are still treated primarily with antisecretory medications, and only 5 percent receive antibiotic therapy. Consumer research by the American Digestive Health Foundation finds that nearly 90 percent of ulcer sufferers are unaware that H. pylori causes ulcers. In fact, nearly 90 percent of those with ulcers blame their ulcers on stress or worry, and 60 percent point to diet.

From the CDC website.
That's interesting. When I took Biology 30 (grade 12 biology in Canada) in the eighties (88?), we learned of H. Pylori and how antibiotic therapy helped ulcers, and of the study protocols that proved why the antibiotics helped (H. Pylori existed and ate away at the stomach lining, and antibiotics killed them). The evidence was quite clear to us students.

Maybe the problem is educating medical personnel after a new discovery is made that is met at first with skepticism? The thing is, the medical personnel went with previous studies and did not incorporate the new information. They were using accepted EBM based on previous studies to treat ulcers. They were using what worked in previous studies to relieve symptoms in studies before new information showed the actual cause of the ulcers. They require evidence before giving their patients new treatments. I imagine newly trained doctors are more informed on new discoveries.

Is there data for after 1995?

[Jeff Corey]

There are, but anecdotal. Students have told me that psychology professors have recently told them that pyloric ulcers are all, or mostly, caused by stress.
The site I cited didn't have later numbers. I think they were trying to make the point that practicioners were not paying attention to the data at that time.

[Eos of the Eons]

I'm still wondering what doctors got what data, and when (if at all). How old is that psychology professor?

I'm finding that it is really tough to get information, unless a person is student.

I was later trained (after high school) as a lab tech, a person that actually has to do research (explain a hypothesis, do a proper laboratory procedure, gather data, and then compare data to control groups, and finally explain if the hypothesis was confirmed or not, and most finally come to a conclusion).

I'm not sure how much of this training medical doctors get, how they get new information and interpret findings, etc. Know what I mean? I think the data after 1995 would be telling, as new doctors began to treat patients.

[Jeff Corey]

At least the Merck Manual got it right. http://www.merck.com/mmhe/sec09/ch121/ch121c.html

[shadron]

I'm not sure how much of this training medical doctors get, how they get new information and interpret findings, etc. Know what I mean? I think the data after 1995 would be telling, as new doctors began to treat patients.

My guess, based upon my observations of the general populace and medical schools, is that they get quite a lot of good information, and they inculcate it readily - up until they get that diploma. Many, immediately following, begin concentrating on their job/business, and their patients, and new technology doesn't get through to them. How many really read the medical journals, phamacology journals, and general science news, and treat that as an investment in their businesses and their patients? Doctors may, as a class, be smarter than the general populace, but they probably are not more ethical, more eager to learn new things, nor anxious to use their spare time for that sort of thing. After all, they know how to treat stomach ulcers - why do they need to learn more about it?

[liverleef]

I work for a clinical information systems vendor installing the very types of systems described in the article. For the most part this is a very good concept. Since so much health data is recorded electronically, it is very easy to identify trends and responses to various treatments. CIS vendors look for ways to utilize this information to guide clinicians in their decision making. I suppose that it is very appealing to hospitals for liability reasons.

[fls]

This illustrates one of the problems
1982
Australian physicians Robin Warren and Barry Marshall first identify the link between Helicobacter pylori (H. pylori) and ulcers, concluding that the bacterium, not stress or diet, causes ulcers. The medical community is slow to accept their findings

1994
A National Institutes of Health Consensus Development Conference concludes that there is a strong association between H. pylori and ulcer disease, and recommends that ulcer patients with H. pylori infection be treated with antibiotics.

1995
Data show that about 75 percent of ulcer patients are still treated primarily with antisecretory medications, and only 5 percent receive antibiotic therapy. Consumer research by the American Digestive Health Foundation finds that nearly 90 percent of ulcer sufferers are unaware that H. pylori causes ulcers. In fact, nearly 90 percent of those with ulcers blame their ulcers on stress or worry, and 60 percent point to diet.

From the CDC website.

The result of using evidence to guide treatment is that change happens after good evidence is available, rather than before. I don't think I would consider that a problem, though.

Linda

[fls]

I work for a clinical information systems vendor installing the very types of systems described in the article. For the most part this is a very good concept. Since so much health data is recorded electronically, it is very easy to identify trends and responses to various treatments. CIS vendors look for ways to utilize this information to guide clinicians in their decision making. I suppose that it is very appealing to hospitals for liability reasons.

Research using administrative and other types of secondary data has been performed for more than twenty years already.

It looks like the money needs to be spent on educating people about what is already happening.

Linda

[fls]

That's interesting. When I took Biology 30 (grade 12 biology in Canada) in the eighties (88?), we learned of H. Pylori and how antibiotic therapy helped ulcers, and of the study protocols that proved why the antibiotics helped (H. Pylori existed and ate away at the stomach lining, and antibiotics killed them). The evidence was quite clear to us students.

Maybe the problem is educating medical personnel after a new discovery is made that is met at first with skepticism?

I suspect what should be met with more skepticism is that the paragraph quoted from the CDC site is representative of the treatment of peptic ulcer disease. It is based on survey data collected in an ongoing manner mostly from primary care physicians. Since the diagnosis of h. pylori necessarily involves a specialist physician (especially at that time), it pretty much guarantees that the bulk of ulcers treated with antibiotics will not be captured by the survey, grossly underrepresenting the degree to which ulcer treatment includes h. pylori treatment.

http://cat.inist.fr/?aModele=afficheN&cpsidt=3183759

Linda

[Ivor the Engineer]

Research using administrative and other types of secondary data has been performed for more than twenty years already.

It looks like the money needs to be spent on educating people about what is already happening.

Linda

That somewhat misses the point. The problems are:

i) Getting the results of research to medical practitioners in the field.

ii) Getting medical practitioners to behave in a way consistent with the best available evidence.

iii) Putting the resources in place to enable (i) and (ii).

What the author of the article was saying in a roundabout way was America needs to get its medical professionals to do more for the same or less remuneration. I'm not sure how many medical professionals would embrace such a change.

[Skeptic Ginger]

This illustrates one of the problems
1982
Australian physicians Robin Warren and Barry Marshall first identify the link between Helicobacter pylori (H. pylori) and ulcers, concluding that the bacterium, not stress or diet, causes ulcers. The medical community is slow to accept their findings.

1994
A National Institutes of Health Consensus Development Conference concludes that there is a strong association between H. pylori and ulcer disease, and recommends that ulcer patients with H. pylori infection be treated with antibiotics.

1995
Data show that about 75 percent of ulcer patients are still treated primarily with antisecretory medications, and only 5 percent receive antibiotic therapy. Consumer research by the American Digestive Health Foundation finds that nearly 90 percent of ulcer sufferers are unaware that H. pylori causes ulcers. In fact, nearly 90 percent of those with ulcers blame their ulcers on stress or worry, and 60 percent point to diet.

From the CDC website.You are correct however, there is another factor one needs to be aware of here. Evidence based medicine is a relatively new concept.

Despite the reference to "physicians" and "healers" throughout recorded history, science only really entered the medical profession in a significant way a mere century ago. And only in the last couple of decades has evidence based medicine become predominant. Medicine is not an art, it is a science. Maybe surgery is an art. But the basis for the surgery is in science. This is not how medicine was viewed as recently as a couple decades ago.

What happens after a discovery such as the H-pylori discovery is it takes a while for the research to be disseminated. So if the op ed is referring to medical providers doing a better job of practicing using up to date standards, then they should address it to the medical community. If it is about the concept of EBM, I think the community gets that part.

[Skeptic Ginger]

I suspect what should be met with more skepticism is that the paragraph quoted from the CDC site is representative of the treatment of peptic ulcer disease. It is based on survey data collected in an ongoing manner mostly from primary care physicians. Since the diagnosis of h. pylori necessarily involves a specialist physician (especially at that time), it pretty much guarantees that the bulk of ulcers treated with antibiotics will not be captured by the survey, grossly underrepresenting the degree to which ulcer treatment includes h. pylori treatment.

http://cat.inist.fr/?aModele=afficheN&cpsidt=3183759

LindaIf only those GPs would consistently refer patients and not treat them then you have a point. I have come across 2 ulcer patients who were treated by GPs in the last couple of years. They were unaware of H-pylori and were not tested or treated for it. This is a very small sample and I notice these kind of omissions since I practice in a specialty.

I think we (as in the medical community as a whole) aren't doing the best job of practicing to the highest standards. But otherwise I do agree with what you are saying.

[ElMondoHummus]

I may be a bit behind the conversation here, but:


Studies have shownthat most health care is not based on clinical studies of what works best and what does not — be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition.


I think I'd like a bit more argumentation and factual support for that assertion. I realize this is an op-ed, not a long piece. But still, it's sort of a weasle-word way of putting things.

[Eos of the Eons]

I suspect what should be met with more skepticism is that the paragraph quoted from the CDC site is representative of the treatment of peptic ulcer disease. It is based on survey data collected in an ongoing manner mostly from primary care physicians. Since the diagnosis of h. pylori necessarily involves a specialist physician (especially at that time), it pretty much guarantees that the bulk of ulcers treated with antibiotics will not be captured by the survey, grossly underrepresenting the degree to which ulcer treatment includes h. pylori treatment.

http://cat.inist.fr/?aModele=afficheN&cpsidt=3183759

Linda

Thank you. That totally makes sense. Agreed.