The Antidote

Counterspin for Health Care and Health News

Thursday, September 28, 2006

Evidence-based health news site recognized

Congratulations to Health News Review for winning a Knight-Batten award from the Institute for Interactive Journalism. Health News Review takes a similar but more formal approach to this blog in looking at the quality of the science behind health stories, and the quality and accuracy of the reporting itself. The reviewers are a team of powerhouses, experts in evidence-based medicine, led by health journalism professor Gary Schwitzer of the University of Minnesota and in collaboration with the Foundation for Informed Medical Decision Making.

What's great about Health News Review, and similar sites in other countries (below), is that it systematically evaluates the accuracy and quality of health news stories. Health journalists, whether they set out to or not, play two roles: providing straight news on health research, care, and policy, and, in the process, providing consumer health information. Because we know that consumers - not to mention health care providers - get health information from the news media and base health decisions on it, it is extremely important that health stories be accurate, understandable, in context, nuanced, and balanced.

Here's how the process works: The reviewers hand-pick stories from the top 50 U.S. newspapers, major TV networks, AP wires, and weekly news magazines. These stories relate to claims about procedures, treatments, and tests for prevention or management of disease, with direct or implied relevance to humans. The reviewers then evaluate the stories on 10 criteria ranging from quality of the evidence to novelty and availability of treatment, a number of stars are assigned for each criterion, and an overall rating is then assigned. Three reviewers rate each story because of the real possibility of disagreements, and the group plans a formal analysis of the consistency and variability of the evaluations.

The group has published over 200 reviews in 5 months, and, according to Schwitzer, reaction from health journalists has been overwhelmingly positive, and demonstrative of their desire for feedback in this complex area of journalism.

Related sites are Media Doctor Australia and Media Doctor Canada.

Wednesday, September 27, 2006

Browsing the health blogosphere

I have spent a fair amount of time wandering around the web the past couple of days, just following links from other blogs I've come across, and I think I'll share the best of it from time to time.

First off, let me dutifully call your attention to today's Skeptics' Circle Blog Carnival #44, which features a number of blogs dedicated to debunking bad science. Probably easier just to send you there than to try and explain what a blog carnival is - I think you'll find it worth the look.

A blog that focuses in part on evidence-based medicine is Blogborygmi; this blogger also hosts blog carnivals, and I'll try and jump on the next one.

Oracknows at Respectful Insolence today had a nice piece on complications of "minor" surgery. I commented there that this is one of the (typically discounted) risks of unproven mass screenings: predictable surgical and other complications are bound to occur during workup, many of which are false positives. More about that in this blog soon, I promise.

Tuesday, September 26, 2006

Health care quality needs a sugar daddy, too

I read a news story today about a huge private infusion of cash, $100 million from Microsoft mogul Paul Allen, towards mapping the thousands of genes that encode the mouse brain, and I felt a pang. It reminded me of this lament about environmental conservation priorities:

"Nobody cares when habitat dies, 'cause habitat doesn't have big brown eyes."

Let me say straight off that I have no doubt that genetic mouse-brain mapping is important and I'm sure there is considerable untapped potential there against neurological diseases, somewhere down the road (and yes, there will be a road, if only because - lest we forget - mice are not people). Microsoft mogul Paul Allen seems to be a "gee whiz" kind of science aficionado, but I wish he'd take a moment to look deeply into the big brown eyes of another health research arena that's just crying out for someone like him: health care quality research.

Some background: the U.S. has the most expensive health care in the world (Reinhardt et al., 2002), but the health care we actually receive lacks quality on a whole-population basis (Crossing the Quality Chasm). A crucial gap appears to lie in the translation from established clinical knowledge into medicine as it's actually practiced. (Hint: it's the systems...) Dr. Steven H. Woolf of Virginia Commonwealth University summed up the issues nicely in a recent Washington Post editorial. Here's one key example Dr. Woolf offers:

Last year, Congress gave $29 billion to the National Institutes of Health, most of it to devise better treatments. The smaller federal agency responsible for solving problems with the delivery of health care, the Agency for Healthcare Research and Quality (AHRQ), received only $320 million.

Health care quality and the issues it comprises - e.g., patient safety, health disparities, health care efficiency - seem to suffer from the same perceived lack of cuteness/sexiness/accessibility as habitat when it comes to public - and private - funding and priorities. As health care costs escalate, the need to address the quality gap becomes that much more urgent. Where's the love, all you do-gooder moguls out there?

Tuesday, September 12, 2006

Big studies: Size isn't everything

My newsfeeder this morning had a news release and a couple of news articles about a big study in Japan that showed that consumption of green tea can reduce deaths from all causes, in particular lowering death from cardiovascular disease. As one of the trendiest, not to mention lucrative, dietary ingredients to hit Western culture in a long time, green tea consumption has been begging for a good study. Personally, since I'm now in the habit of laying out $3.50 a pop for a Starbucks green tea frappuccino, I'm curious to know whether I'm getting anything for my money besides sugar, milk, and a mild caffeine buzz. I hope I'm not alone in my curiosity - as I've said before, consumers have a right to know whether the supplements they shell out money for actually do what they're supposed to do.

The study is big, really big, not just in terms of all participants, but also in the numbers of those who died; both are important for robustness - it means the sample will hold up to a lot of subgroup or multivariable analyses with which one controls for confounders. The researchers followed 40,530 healthy Japanese adults, observed what they ate (among 36 foods) and drank (black, green, and oolong tea, and coffee), obtained information at baseline on a few other lifestyle factors, and measured their causes of death. The cohort was followed for 11 years for deaths due to all causes and up to 7 years for deaths due to specific causes.

People who drank 5 or more cups a day experienced the most apparent benefit; death from all causes was reduced by 12% for men and 23% for women, and women who drank 3-4 cups also experienced statistically significant benefit. When the sex groups were combined, there was an all-cause mortality benefit only in the 5+ cups/day group. Similar benefits to the overall mortality results were seen for cardiovascular disease deaths (after 11 years of follow-up), but no apparent benefit (or risk) was seen for cancer deaths.

So what does it all mean? Well, first of all, this is a pretty darn good study, but it can't prove that green tea actually prevents death from cardiovascular disease and all causes. That's because there may be other factors that the study was unable to anticipate or measure that were associated with both green tea drinking and reduced mortality (though they did account for some good ones, as noted above). Also, dietary measurement is notoriously lousy, and that could have resulted in some undercounting as well, possibly even in a systematic way between heavy and lighter tea drinkers, for example. A study that could prove benefit, and also prove safety, would also have to be fairly large to look at deaths as an outcome, but would also have to be randomized, and since ethical issues associated with randomizing people to drink green tea are obscure to this writer, you might be able to do it. A large randomized study would be quite expensive though, and who would pay for it? Green tea manufacturers? I doubt it. Until consumers really come to understand the hierarchy of study designs - hint! - there just may not be a demand for it. Until then I guess I'll just have to keep jumping up and down.

Something else to think about - the very large number of people in the study who drank 5 or more cups of green tea a day. Could we do it in the U.S.? That is, sign up several thousand people and get them to drink all that tea, or some placebo, and what would that placebo be?

I'll be interested to see whether actual public health recommendations come out of this study.

Thursday, September 07, 2006

The new Medicare drug benefits: good news or bad news?

I expect that we'll see a lot of news in the next couple of days spinning the new survey from the Kaiser Family Foundation of physicians and pharmacists on the recently implemented Medicare prescription drug benefits. If I'm wrong and it doesn't catch the interest of the media, well, that's a shame, because these numbers are very interesting and potentially very important.

Here's the news release from the KFF. It starts out with a bit of a good news/bad news take:
Substantial majorities of pharmacists (86%) and physicians (71%) believe that the prescription drug law is helping people on Medicare save money on their medications, according to two new national surveys conducted by the Kaiser Family Foundation.

At the same time, pharmacists (91%) and doctors (92%) believe the law is too complicated. A majority in both professions report that Medicare beneficiaries who they see are encountering problems in getting their medications, sometimes with serious consequences.

“We have surveyed seniors many times, and now pharmacists and doctors, and the story is remarkably consistent: The benefit is providing help to millions as intended, but there are also problems, and the complexity of the law is an issue for many,” said Kaiser Family Foundation President and CEO Drew E. Altman, Ph.D.

I thought I'd look a little more closely at the bad news, because the good news - that substantial majorities of pharmacists and physicians think that people are being helped - just sounds so hopeful. Here are a few select numbers that jumped out at me (and you can look at the data yourself here and draw your own conclusions):

I'm going to focus on the pharmacists here because 84% of them say they have experience with the new Medicare drug benefits compared with only 44% of doctors who say they have experience.
  • 81% of pharmacists have customers who have problems getting their meds
  • 45% of pharmacists have a favorable impression of the Medicare program, compared with a full 41% who have an unfavorable impression
  • 40% of pharmacists would give the program a grade of C
  • 86% say their customers don't understand the benefit well
  • 53% say the administrative burden is worse than that of typical insurance plans
  • 91% of pharmacists say the benefit is too complicated (59% strongly agree, 32% somewhat agree)
  • 62% either strongly or somewhat agree that the program benefits health plans and pharmaceutical companies too much
  • 82% of pharmacists somewhat or strongly agree that the program helps save people money, particularly for low-income people.
just a couple of salient items on doctors:
  • benefit
  • 69% of docs reported that they are not very or at all familiar with the Medicare drug benefit formularies
There are a lot of questions here that beg for answers. (Another Kaiser survey of seniors themselves is available and had similar results.) I'm still hung up on the 10% of docs who had a with a serious medical consequence. To me, that sounds like a lot. How do we value it against the cost savings that pharmacists say their customers receive? That's one for the bioethicists. What about the perceived benefit to health plans and pharmaceutical companies - how does that work? Are things at least improving over time? (These data were collected between April and July of this year, too short a time frame to see real changes, though that wasn't the intent of the survey.) Finally, how will this survey's results play in Washington, now that Medicare and Medicaid administrator Mark McClellan has chosen to step down?

As always, thoughts and comments welcome...

More on autism

Hurrah! I have a present for you: it's a free, full-text article from the journal Pediatrics, specifically a critical review of the epidemiologic evidence regarding the putative link between mercury and autism, by Parker and colleagues at the University of California Health Sciences Center (2004).

In this article you will read about the highest quality studies available on the topic, prospective cohort studies comparing children exposed to thimerosal-containing vaccines to similar children who received vaccines without thimerosal. These studies showed that the two groups had similar risk of being diagnosed with autism or autistic spectrum disorders (ASD). Prospective studies are extremely important for diseases whose diagnostic criteria for a disease are fuzzy, or changing, or both; much of the apparent increase in autism, as I mentioned in my post earlier this week, does appear to be due largely to expanded diagnostic criteria.

The studies that didn't pass muster were studies that compared changes in rates of autism diagnoses in a population over time to changes in mercury content of vaccines. These are ecologic studies, and while they sound compelling, and can even be used to generate hypotheses, they have a fatal design flaw: the lack of individual-level information on other factors that are associated with exposures or disease. (Another example is dietary fat and breast cancer: countries with high fat consumption also have high breast cancer incidence, but there could be 100 other things that explain this apparent association, and without individual-level information, you can't control for them.)

I read some other interesting comments from scientists along the way; one went so far as to suggest that the pathology of autism suggested that postnatal environmental risk factors are "unlikely" (Taylor B, Child Care Health Dev 2006; 32:511-519). (Paternal age would be a good example of a prenatal risk factor, and not just because prenatal, parental, and paternal just happen to be anagrams of one another... oh, never mind.) Certainly the expanded diagnostic criteria should be taken into account in any epidemiologic study. The fact that we don't have good incidence and prevalence data on autism makes the aforementioned ecologic studies that much less reliable.

Also check out the extensive coverage of this issue in the blogosphere at Respectful Insolence (and I mean extensive; I've not gotten through all of it myself).

Tuesday, September 05, 2006

Autism and paternal age: let's hear it for population-based studies

Today's Washington Post has a nice article by Shankar Vedantam about the association between increasing paternal age and risk of autism. Vedantam does a great job of laying out the context for readers: what you need to know about autism; what you need to know about paternal age; and a hint at some of the controversy over autism research, one aspect of which is whether an apparent epidemic of the disease may be in part attributable to expanding diagnostic criteria.

The beauty of this study, published in the September issue of the Archives of General Psychiatry, is that it followed the health of 98% of males, and 75% of females, born in Israel during a 6-year period in the 1980s, based on clinical army-enrollment exams. (The lower number for females is explained by Orthodox Jewish women not being required to enlist in the army.) That's a pretty complete picture. Final diagnoses were assigned at age 17 by draft-board psychiatrists, either in person or based on years of clinical data referred to the draft-board docs. The authors point out that the majority of these diagnoses were made before expanded diagnostic criteria were used, so that the numbers were not inflated - in fact, the numbers were quite small, inconveniently so for the researchers, because multivariable analyses are difficult with small numbers.

The reason that population-based estimates are more valid is that they are less susceptible to selection bias. Selection bias has the potential to leave disproportionate numbers of people with an unmeasured risk factor, or confounder, in one of the comparison groups relative to another. As a result, a measured association may be artificially inflated. In the case of this study, since the study sample for the country was so complete (everyone has to show up to the draft board), the chance that people were not included because of a diagnosis of autism or because of paternal age was essentially eliminated.

Friday, September 01, 2006

What is a breakthrough, anyway?

The first article I saw on this week's Science Magazine article on gene therapy and melanoma was in the Wall Street Journal; their headline reads "Scientists Use Gene Therapy to Shrink Malignant Tumors: Study is Hailed as Potential Cancer Breakthrough." I read the word "breakthrough" and it made me sneeze, as always. So even though the breakthrough was qualified as "potential," I thought it'd be fair to look it up.

The American Heritage Dictionary, 3rd ed., defines "breakthrough" (n), thus: 1. An act of overcoming or penetrating an obstacle or restriction. 2. A military offensive that penetrates an enemy's lines of defense. 3. A major achievement or success that permits further progress, as in technology.

My question to the dictionary editors would be this: how do you define "major" and "permits further progress"? Shouldn't every incremental advance in scientific knowledge permit further progress? According to the press release from the National Institutes of Health, the gene therapy took (i.e., produced major tumor regression) in only two of the 17 patients in whom it was tested (though that didn't stop NIH scientists from hyping the results further). Nobel laureate David Baltimore, who does similar research, pointed out that there were no controls in the study, according to the WSJ, which means that the study can't prove that the treatment worked - although highly unlikely, the tumors could have regressed on their own.

After reading the American Heritage's definition, I feel a little less allergic to the word breakthrough. I'd be willing to accept that this is an important finding from the perspective of scientists; for example, according to NIH Director Elias Zerhouni, "These results represent the first time gene therapy has been used successfully to treat cancer" (again, from the science point of view, I might grant him successful). But what does the word "breakthrough" convey to the casual reader of a newspaper? to someone who wants to invest in cancer-treatment technologies? or to a patient with melanoma who's not in the study? Headline writers love the word; it sells papers. But can it also sell false hope?

For further analysis on news coverage of this story, check out Gary Schwitzer's blog.

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