From: Djulbegovic, Benjamin <[log in to unmask]>
Subject: Re: Mammography Screening Info from BMJonline
To: [log in to unmask]
Date: Sunday, 1 February, 2009, 5:01 PM

The problem, of course, is that the end of the day, and when everything is said and done, we are left with “the problem of single case”-uncertainty about applying of trial (“group averages”) data to bedside. In case of Ash’s renal cancer patient the crucial word here is “probable” i.e. that  the patient will most PROBABLY die within 3 months despite of taking £40000 worth of new anti cancer medication? But, in the patient’s case it is always 0 or 1, i.e.  the knowledge of class probability cannot tell us anything about a particular case at hand, which is the reason that we continue to see that decisions are being made by majority of practitioners ( myself included, doing it on almost daily basis). When this discussion is further extended, it inevitably leads to the most uncomfortable questions of all: what is price of hope, uncertainty, or life for that matter? (many economists model the price of life at $6 millions).

EBM cannot help here- ultimately it is going to require broader societal consensus related to group vs. individual interests. What EBM bets on is that these decisions may become more palatable if we finally acknowledge that one of the key problems in medical practice and chief source of  uncertainty  is the lack of reliable information and poor quality evidence that inform most our medical decisions. In many cases, what we used to believe is a small probability of BENEFIT turned out to be not so small probability for HARMS.

ben

 

 

 

Benjamin Djulbegovic, MD, PhD

Professor of Medicine and Oncology

Co-Director of Clinical Translation Science Institute

Director of Center for Evidence-based Medicine and Health Outcomes Research

 

From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Paul Alexander
Sent: Sunday, February 01, 2009 9:02 AM
To: [log in to unmask]
Subject: Re: Mammography Screening Info from BMJonline

 

Good day, this string is excellent and raises again the important issue of applying EBM to decision making in the increasing era of budget cutbacks and tightening. The issue is that to make the best cost effective decisions, we need the good sound evidence to back it up and share this with the patient in a patient focused manner. This is a very challenging area for there are the ethics of decison making and funding one at the cost of the other...I agree with Dr Paul Ash that the issue is a lack of these issues being dealt with in the medical schools. Clinical epidemiology, EBM, cost effectiveness etc. must be focused on. Explaining the risks and benefits to the patient can go a long way.   I support the EBM approach and think that well applied, can be very useful and important in an era of cutbacks and funding challenges. For the most cost effective decision, options.           Best,   Paul     --- On Sun, 2/1/09, Ash Paul <[log in to unmask]> wrote: From: Ash Paul <[log in to unmask]> Subject: Re: Mammography Screening Info from BMJonline To: [log in to unmask] Date: Sunday, February 1, 2009, 4:38 AM Dear Douglas, You moderate an outstandingly excellent e-group (and one that I'm proud to be a member of, albeit mostly a silent member) but I agree with Neal, Marcus and Frederico, speaking with my NHS PCT commissioners hat on, we do need to discuss these sensitive topics openly and boldly in excellent internationally respected e-groups groups like this. Neil is absolutely right, most busy clinicians, the lay public and the politicians have no concept about relative and absolute risk and more worringly, many of the clinical leaders have no understanding of epidemiology, population medicine and cost effectiveness. It is also a relatively neglected topic in the medical school curriculum. What we need to consider in the UK is how can we apply evidence-based medicine effectively in order to improve the health of the population and reduce health inequalities within the NHS. All of us clinicians should feel ashamed that in 29 years since the Black Report was first published in 1980, health inequalities in Britain have gone up by a further 2 years inspite of the many extra billions spent on the NHS. To spend £40000 of NHS money on a new cancer drug for a single patient with a fourth relapse of multiple myeloma is in my mind, not a good use of the practice of evidenced-based medicine, because it deprives me as an NHS commissioner from investing £40000 pounds in palliative care for the entire community. As clinicians, we must learn not to peddle immortality to patients on the back of evidence-based medicine. We must also consider how we can use evidence-based medicine to prepare proper information aids for patients. Why should I as the PCT's Medical Director have to tell the renal cancer patient that s/he will most probably die within 3 months inspite of taking £40000 worth of new anti cancer medication? Surely that is the duty of the clinician who prescribes the medicine using his or her knowledge of evidence-based medicine to properly explain the risks and benefits of the drug to his/her patient?  Academicians and researchers on the other hand, have no practical idea how difficult it is for NHS PCT public health commissioners to convince clinicians about the practical applications of evidence-based medicine and its use in commissioning in a finitely funded healthcare system. They have no idea of opportunity costs and the ethics of commissioning. In a finitely funded healthcare system, the medical ethics of autonomy which explores individual doctor patient relationships, needs to give way to the public health ethics of interdependence ie the realisation that funding one patient on the back of dubious and badly interpreted evidence actually affects the health and welllbeing of the entire community through opportunity cost. The days of EBM surviving and flourishing within an academic silo have long gone, and if they haven't, they soon will, with the present global financial crisis affecting publicly funded healthcare systems next on its hit list. If you speak to Sir Muir Gray, Chief Knowledge Officer of the NHS and Professor at Oxford and the guru of EBM, and who I'm sure you know very well already, I'm absolutely convinced that he will confirm everything that Neal, Marcus and Frederico have written here. In fact, I'm willing to stake my life on that and I'm copying Sir Muir into this email as well. Regards, Ash Dr Ash Paul Medical Director                             NHS Bedfordshire  Gilbert Hitchcock House 21 Kimbolton Road Bedford MK40 2AW ( 01234 795705 4 01234 745896 * [log in to unmask]" target=_blank rel=nofollow>[log in to unmask]     --- On Fri, 30/1/09, Marcus Tolentino Silva <[log in to unmask]> wrote: From: Marcus Tolentino Silva <[log in to unmask]> Subject: RES: R: ENC: [Consumers] Mammography Screening Info from BMJonline To: [log in to unmask] Date: Friday, 30 January, 2009, 8:10 PM Apparently, researchers that work with EBM and HTA like to speak of his finds for others researchers that works with EBM and HTA. It looks me that this vicious circle does with that the dissemination examples of the knowledge in EBM and HTA prompt the natural resistance by some researchers.   -----Mensagem original----- De: Evidence based health (EBH) [mailto:[log in to unmask]] Em nome de Maskrey Neal Enviada em: sexta-feira, 30 de janeiro de 2009 13:30 Para: [log in to unmask] Assunto: Re: R: ENC: [Consumers] Mammography Screening Info from BMJonline   Bravo, Frederico!   If the EBM movement focuses on processes and methodological issues only (important though those are) and fails to address the issues of fair accurate and balanced translation of the best available evidence in ways that patients, the public and busy clinicians can readily understand, then we are in trouble.   Mammography screening is an excellent example of the issues. Most clinicans and almost all patients can't get to grips with relative and absolute risk despite 20 years of industrial strength, traditional  EBM teaching and writing. We need to find ways of helping them that are innovative, because the current approaches are not working.   Bw   Neal   Neal Maskrey National Prescribing Centre Liverpool UK       -----Original Message----- From: Evidence based health (EBH) <[log in to unmask]> To: [log in to unmask] <[log in to unmask]> Sent: Fri Jan 30 12:21:45 2009 Subject: R: ENC: [Consumers] Mammography Screening Info from BMJonline   [forgive my English] I don't agree, Douglas. Debate about mammography screening is at present one of the most important methodologic arena for Evidence Base Health. We need to talk extensively about it. Kind regards.   dott. Federico Barbani Servizio Committenza (health purchasing service) Azienda USL di Modena via San Giovanni del Cantone 23 41100 MODENA, Italy tel 059/435813 - 435731   -----Messaggio originale----- Da: Evidence based health (EBH) [mailto:[log in to unmask]] Per conto di Douglas Badenoch Inviato: venerdì 30 gennaio 2009 13.08 A: [log in to unmask] Oggetto: Re: ENC: [Consumers] Mammography Screening Info from BMJonline   Just a quick reminder to list members, please don't post attachments to the list.   Instead you should either post a link to the document, or offer to email it to people who are interested.   Secondly, I think that this message would be better on a topic-specific list, such as one dedicated to women's health, rather than on EBH, which is about issues relating to the process of EBH.   I guess there may be generic, process-type questions which may arise from this, such as how to achieve truly evidence-informed patient choice, but I would look to the original author to state what that question is.   Thanks   Douglas [log in to unmask]   Marcus Tolentino Silva wrote: >  >   > ---------------------------------------------------------------------- > -- > *De:* Maryann Napoli [mailto:[log in to unmask]] *Enviada em:* > quinta-feira, 29 de janeiro de 2009 14:43 > *Para:* [log in to unmask] > *Assunto:* [Consumers] Mammography Screening Info from BMJonline >   > Mammography stands out from all other cancer screening tests with the > quantity and quality of its research support.  Yet the documented > harms associated with this procedure are withheld from women (no > matter where they live).  This is the message of the attached article > from BMJ online with authors from the Nordic Cochrane Centre and > University of Copenhagen.  The other attachment (from same authors)  > is, in my opinion, the first honest pamphlet aimed at women who want > to make an informed decision whether or not to undergo mammography > screening. >   >  >   > Best wishes, >   >  >   > Maryann Napoli > Center for Medical Consumers > 239 Thompson St. > New York, New York 10012 > 1(212) 674-7105 > www.medicalconsumers.org <http://www.medicalconsumers.org> > [log in to unmask] <mailto:[log in to unmask]> >   > . >     -- Mr Douglas Badenoch Director, Minervation Ltd ------------------------- 23 Bonaly Grove Edinburgh EH13 0QB ------------------------- Tel:  +44 131 441 4699 Web:  www.minervation.com ------------------------- Minervation is a limited company registered in England and Wales Registered number: 4135916 VAT number: 792674384 Registered Office: Salter's Boat Yard, Folly Bridge, Abingdon Road, Oxford, OX1 4LB

 

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