A lost opportunity to have transparent information on improper financial relationships between industry and healthcare professionals
“In February, the Scottish government formally rejected a petition to introduce legislation that would have created a searchable record of all payments to healthcare professionals from the pharmaceutical and medical device industries.
“Sunshine” legislation has been enacted elsewhere, including in the US, Australia, and Japan, and there are voluntary efforts in the UK, Germany, and Canada.
The decision is a lost opportunity for Scottish citizens to have transparent information on the financial relationships between industry and their doctors and other healthcare professionals.”…
Read Kept in the dark: Scotland rejects “sunshine” legislation, on The BMJ, 29 March 2019.
Read Scotland rejects “sunshine” legislation on searchable database of industry payments, on The BMJ, 29 March 2019.
hrHPV testing with an appropriate assay offers a promising new strategy that could increase population coverage substantially
What is already known on this topic
- Tests performed on self samples are less sensitive and less specific than tests performed on clinician samples when using a high-risk human papillomavirus (hrHPV) assay based on signal amplification
- Response rates for hrHPV testing are higher for self sampling kits than for conventional invitations
What this study adds
- Tests performed on self samples are similarly sensitive and slightly less specific than tests performed on clinician samples when using a hrHPV assay based on polymerase chain reaction
- Response rates for hrHPV testing continue to be higher for self sampling kits than for conventional invitations
2018 Study Abstract
To evaluate the diagnostic accuracy of high-risk human papillomavirus (hrHPV) assays on self samples and the efficacy of self sampling strategies to reach underscreened women.
Medline (PubMed), Embase, and CENTRAL from 1 January 2013 to 15 April 2018 (accuracy review), and 1 January 2014 to 15 April 2018 (participation review).
Accuracy review: hrHPV assay on a vaginal self sample and a clinician sample; and verification of the presence of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) by colposcopy and biopsy in all enrolled women or in women with positive tests. Participation review: study population included women who were irregularly or never screened; women in the self sampling arm (intervention arm) were invited to collect a self sample for hrHPV testing; women in the control arm were invited or reminded to undergo a screening test on a clinician sample; participation in both arms was documented; and a population minimum of 400 women.
56 accuracy studies and 25 participation trials were included. hrHPV assays based on polymerase chain reaction were as sensitive on self samples as on clinician samples to detect CIN2+ or CIN3+ (pooled ratio 0.99, 95% confidence interval 0.97 to 1.02). However, hrHPV assays based on signal amplification were less sensitive on self samples (pooled ratio 0.85, 95% confidence interval 0.80 to 0.89). The specificity to exclude CIN2+ was 2% or 4% lower on self samples than on clinician samples, for hrHPV assays based on polymerase chain reaction or signal amplification, respectively. Mailing self sample kits to the woman’s home address generated higher response rates to have a sample taken by a clinician than invitation or reminder letters (pooled relative participation in intention-to-treat-analysis of 2.33, 95% confidence interval 1.86 to 2.91). Opt-in strategies where women had to request a self sampling kit were generally not more effective than invitation letters (relative participation of 1.22, 95% confidence interval 0.93 to 1.61). Direct offer of self sampling devices to women in communities that were underscreened generated high participation rates (>75%). Substantial interstudy heterogeneity was noted (I2>95%).
When used with hrHPV assays based on polymerase chain reaction, testing on self samples was similarly accurate as on clinician samples. Offering self sampling kits generally is more effective in reaching underscreened women than sending invitations. However, since response rates are highly variable among settings, pilots should be set up before regional or national roll out of self sampling strategies.
Whereas accuracy of new combinations of assays and self sampling devices can be evaluated in a diagnostic setting, acceptance and participation should be shown locally in a screening setting before general roll out.
New UK recommendations emphasise shared decision making
As the tree of overdiagnosis has grown, efforts have been made to trim the branches. Initiatives such as Preventing Overdiagnosis, Too Much Medicine, Slow Medicine aim to increase our understanding of how it manifests itself. Efforts such as Choosing Wisely are underway to affect policy and change patient expectations and to change well-entrenched medical practices.
Overdiagnosis and overtreatment are common, harmful to patients, and expensive. Doctors and patients tend to overestimate the benefit and underestimate harm of interventions. Choosing Wisely is a medically led campaign focusing on engaging doctors and patients in decisions about potentially unnecessary medical tests, treatments, and procedures. It started in the US in 2012 and has now been taken up in 22 countries worldwide, including the UK.
Read the full text on The BMJ, 2018.
“Helping patients choose wisely”
This statement grandly assumes that patients have no wisdom. Whilst it might well apply to many patients, there are equally many who are very well aware and informed of the best course of action to be taken.
bm Patient Karyse Day’s response, 2018.
“Ironically, even though it causes harm, the effects of overdiagnosis look like benefits. People with disease that is overdiagnosed do well because, by definition, their disease was non-progressive. They are “cured” when cure was not necessary in the first place. This creates a cycle that reinforces efforts leading to more overdiagnosis. “
Healthcare is in a tailspin as the rush to offer technology and services turns otherwise healthy people into concerned patients by identifying disease that is not destined to cause them harm.
Why overdiagnosis is hard to spot and to explain to individuals
Overdiagnosis, sometimes known as “pseudodisease,” turns people into patients unnecessarily. It identifies deviations, abnormalities, risk factors, and pathologies that were never destined to cause harm (such as symptoms, disability, or death). Overdiagnosis causes anxiety and other negative consequences of labelling; it leads to wasted resources and side effects as a result of unnecessary treatment. Here we consider overdiagnosis in asymptomatic people. Overdiagnosis also occurs (and causes harm) in symptomatic individuals when expanded disease definitions overmedicalise unpleasant ordinary life experiences, but we do not consider it here due to distinct conceptual differences between the two in terms of driving causes and ability to identify overdiagnosis in individuals.
Real but elusive trigger of too much medicine
Overtesting and overtreatment can be identified in a given patient. There is a consensus based on solid evidence that a patient with low back pain but without specific neurological signs or deficits who undergoes magnetic resonance imaging of the spine…
… continue reading on The BMJ, 17 August 2018.
Image credit newlifefoundation.
Cumulative meta-analysis gives extra insights
Sodium valproate is licensed in the EU for treating generalised, partial or other forms of epilepsy. It has also been used to treat bipolar disorder and to prevent migraine. In February of this year, the European Medicines Agency recommended that sodium valproate should not be used during pregnancy unless no other effective treatment is available, and that it must not be used in women able to have children, unless the conditions of a pregnancy prevention programme are met. These measures to protect women and their children are welcome, but we argue that they should have been instituted several years ago, as the evidence was clear as far back as 1990 that there were risks of congenital malformations in women exposed to valproate.
Our analysis shows the value of cumulative meta-analysis, which, in our view, should be performed as standard in systematic reviews when any concerns about harms arise during the use of medications. …
…, we consider that drug companies, journal editors, prescribers and systematic reviewers have all acted too late. We, therefore, consider that from 1990 individuals should have been offered the opportunity to switch to treatments with lower risks, where they existed, and given minimum effective doses of valproate if alternative treatments were not available or advisable. In the intervening years, many women’s children will have been harmed. Manufacturers and regulators should be responsible for ensuring that cumulative analyses are carried out as part of postmarketing risk management plans.
Association between neighbourhood air pollution concentrations and dispensed medication for psychiatric disorders in a large longitudinal cohort of Swedish children and adolescents
To investigate associations between exposure to air pollution and child and adolescent mental health.
Swedish National Register data on dispensed medications for a broad range of psychiatric disorders, including sedative medications, sleeping pills and antipsychotic medications, together with socioeconomic and demographic data and a national land use regression model for air pollution concentrations for NO2, PM10 and PM2.5.
The entire population under 18 years of age in 4 major counties. We excluded cohort members whose parents had dispensed a medication in the same medication group since the start date of the register. The cohort size was 552 221.
Main outcome measures
Cox proportional hazards models to estimate HRs and their 95% CIs for the outcomes, adjusted for individual-level and group-level characteristics.
The average length of follow-up was 3.5 years, with an average number of events per 1000 cohort members of ∼21. The mean annual level of NO2 was 9.8 µg/m3. Children and adolescents living in areas with higher air pollution concentrations were more likely to have a dispensed medication for a psychiatric disorder during follow-up (HR=1.09, 95% CI 1.06 to 1.12, associated with a 10 µg/m3 increase in NO2). The association with NO2 was clearly present in 3 out of 4 counties in the study area; however, no statistically significant heterogeneity was detected.
There may be a link between exposure to air pollution and dispensed medications for certain psychiatric disorders in children and adolescents even at the relatively low levels of air pollution in the study regions. The findings should be corroborated by others.
The Guardian press releases : here, here, here, here, here, here.
Identifying the evidence that matters, keeping up to date and applying evidence in practice is a significant challenge for busy clinicians
When the BMJ Evidence-Based Medicine Journal was launched, about 10,500 randomised trials were indexed on PubMed. Identifying the trials that affect practice has become harder: 20 years later, over 30,000 trials are published annually. If we focused purely on systematic reviews, we would face similar problems: over 19,000 systematic reviews were indexed on PubMed in 2017.
As a result, the BMJ EBM Journal has set out to identify, and focus on, the research evidence that provides definitive conclusions and research that confirms, refutes or improves current practice.
The EBM Journal has focused on two questions:
- does this research apply to the patients we see in practice?
- and what difference could this evidence make to my patient?
In doing so, the BMJ EBM Journal can remove a substantial amount of research that does not matter.
Read Introducing the EBM Verdict: research evidence relevant to clinical practice, bestpractice.bmj, 2019.
What is the best research evidence and how to find it
Evidence-based medicine (EBM) refers to the application of the best available research to clinical care, which requires the integration of evidence with clinical expertise and patient values.
- Why is research evidence better than expert opinion alone?
- What studies are more reliable?
- Why we shouldn’t read studies
- Why we should read systematic reviewsThree reasons why we shouldn’t read (most) systematic reviews
- Three alternatives to access the best evidence?
- Pick the best systematic review
- Read trustworthy guidelines
- Use point-of-care tools
- The future
Read What is the best evidence and how to find it, bestpractice.bmj, 2019.
The Cochrane HPV vaccine review was incomplete and ignored important evidence of bias
In May 2018, the Cochrane Collaboration published its review of the human papillomavirus (HPV) vaccines. The review primarily assessed the vaccines’ effect on precursors to cervical cancer. Cochrane has high standards for its reviews; however, there were important limitations in its HPV vaccine review, which we address in this paper.
- The Cochrane human papillomavirus (HPV) vaccine review missed nearly half of the eligible trials
- No included trial in the Cochrane review used a placebo comparator
- The included HPV vaccine trials used composite surrogate outcomes for cervical cancer
- The Cochrane review incompletely assessed serious and systemic adverse events
- The Cochrane review did not assess HPV vaccine-related safety signals
- Industry trial funding and other conflicts of interest
- Cochrane’s public relations of the review were uncritical
Part of the Cochrane Collaboration’s motto is ‘Trusted evidence’. We do not find the Cochrane HPV vaccine review to be ‘Trusted evidence’, as it was influenced by reporting bias and biased trial designs. We believe that the Cochrane review does not meet the standards for Cochrane reviews or the needs of the citizens or healthcare providers that consult Cochrane reviews to make ‘Informed decisions’, which also is part of Cochrane’s motto. We recommend that authors of Cochrane reviews make every effort to identify all trials and their limitations and conduct reviews accordingly.
Read the author’s full paper on The BMJ.
The short story of a long journey to get into the public domain unpublished data, methodological flaws and bias of the Cochrane HPV vaccines review
Cochrane meta-analyses are considered the gold standard to assess public health interventions’ benefits and risks. Cochrane reviews shall apply evidence-based medicine (EBM) methodology on the best available evidence; they shall adhere to strict ethical guidelines as authors of Cochrane reviews are supposed to not have bias, nor conflicts of interest. Our 6 years’ documented case on the Cochrane human papillomavirus (HPV) vaccines review demonstrates that Cochrane guidelines can fail. According to EBM standards, such relevant methodological and ethical flaws void Cochrane positive conclusions on HPV vaccines efficacy.
Cochrane published a review of the human papillomavirus (HPV) vaccines on 9 May 2018. On 4 June, we submitted a detailed analysis of this review as a comment via the Cochrane website.
Our comment highlights serious methodological flaws in the review:
(A) studies’ quality not properly assessed;
(B) post hoc subgroup analyses presented as randomised controlled trial results;
(C) reporting bias not acknowledged;
(D) selective reporting not taken into consideration;
(E) biased trial designs;
(F) unpublished data not included;
(G) conflict of interests (COI) in the authors’ group;
(H) n=7 studies on Gardasil included, n=18 for Cervarix—the latter not being marketed in the USA anymore.
… continue reading on The BMJ, by Catherine Riva, December 2018.
visit re-check ref hpv-vaccination.
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