Dr David Spriggs. General Physician and Geriatrician Auckland City Hospital Auckland. 16:30-16:55 The Sceptics View of Evidence Based Medicine.

Transcription

1 Dr David Spriggs General Physician and Geriatrician Auckland City Hospital Auckland 16:30-16:55 The Sceptics View of Evidence Based Medicine.

2 David Spriggs General Physician/Geriatrician Auckland District Health Board

3 Disclosures No links with Pharma Full time public service employee of ADHB A significant part of this work is based on

4 Credulity Scale Cynical Nihilist Sceptical Suggestible Gullible

5 EBM Achievements Clinical Practice more Scientific Improved safety and consistency Collation and summary of evidence (Cochrane) Methodology and standards for research Development of infrastructures for updating information Teaching of critical appraisal Building knowledge base that is global and accessible

6 EBM Problems Cheapening of the Quality Mark Glargine vs Protophane Diabetic Medicine 2008;25:

7 Diabetic Medicine 2008;25: Exclusive Day time hypoglycaemia occurred in 25.7% Protophane Vs 33.9% Glargine. These figures not quoted or analysed if only 50% of those using analogue insulins had been put on human insulin instead the NHS would have saved close to 250m in the cost of insulin over the past five years. BMJ 2010;341:c7139

8 Lack of consensus Thrombolysis in AIS Alteplase for treatment of acute ischaemic stroke: independent review From: Medicines and Healthcare products Regulatory Agency First published: 24 July 2015 the benefit of alteplase in the treatment of stroke outweighs the risk when used in accordance with the product licence ie, up to 4.5 hours after symptom onset

9 The NNT Quick summaries of Evidence Based medicine Thrombolytics for Acute Ischemic Stroke No benefit found In Summary, for those who received the thrombolytics: Benefits in NNT 100% saw no consistent reliable patient-oriented benefit None were helped (stroke symptoms improved) Harms in NNH 5% were harmed by a symptomatic intracranial hemorrhage 1 in 20 were harmed (symptomatic intracranial hemorrhage)

10 12 RCTs of Thrombolysis Benefit No Benefit Stopped Early or harm

11 Evidence can be made to show whatever you want.

12 Information Overload The number of systematic reviews in health care, 1990 to Bastian H, Glasziou P, Chalmers I (2010) Seventy-Five Trials and Eleven Systematic Reviews a Day: How Will We Ever Keep Up?. PLoS Med 7(9): e doi: /journal.pmed

13 The rise in non-systematic reviews, case reports, trials, and systematic reviews, 1950 to 2007 (as identified in MEDLINE). Bastian H, Glasziou P, Chalmers I (2010) Seventy-Five Trials and Eleven Systematic Reviews a Day: How Will We Ever Keep Up?. PLoS Med 7(9): e doi: /journal.pmed

14 Guideline Epidemic guidelines on prevention and treatment of cardiovascular disease

15 Disease Mongering 1024 men Mean age 57years, BMI 25.6 kg/m2 Prevalence Sleep Moderate/severe Sleep disordered breathing = 49.7%

16 Disease Mongering 1024 men Mean age 57years, BMI 25.6 kg/m2 Prevalence Sleep Moderate/severe Sleep disordered breathing = 49.7% Sponsored by GlaxoSmithKline and others

17 Thorax 2014;69;1128

18 Over-diagnosis Prevalence of Chronic Kidney Disease in US by 2012 Classification One in eight Adults have CKD Moynihan R et al. BMJ 2013;347:bmj.f4298

19 Guideline Epidemic

20 Over treatment Sales of Bisphosphonates tripled from 2001 to 2008 Expected to exceed $11bn in 2015 Systemic review of 23 studies relative risk reduction of NOF of 0.68 ( ) NNT = 175 patients for three years to prevent one NOF

21 Finland Guidelines BMJ 2011;342:d2175

22 Bribes and Subversion 2006 Pharma spend >$5.5bn in drug promotion in US More than all US medical Schools (NEJM 2007) I rep per 4.7 doctors Thanks Prof Cindy Farquhar

23 Lack of effectiveness Accessed 10/9/15

24 Targets and Algorithms Quality Outcomes Framework (UK) Links 25% GPs incomes to over 100 evidence based quality indicators mainly WRT Chronic disease prevention. Cost 1Billion Pounds per year the grand experiment forged by the tools and inspired by the philosophies of Evidence Based medicine has dwarfed other attempts to bring pay for performance into primary care. Prof Grant Russell, Monash Uni BMJ 2 nd March

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26 Multi-morbidity Barnett. Lancet 2012; 380:37-43

27 JAMA 2005;

28 Who/What is the unit of care in EBM? Population Economy Health services Health providers Pharmaceutical industry The Family The individual Patient Diseases Risk factors (non-diseases) Lab tests Red = EBM outcomes measures

29 Summary for EBM Too much of it Doesn t tell us what we need to know Is subject to varying interpretation Can not apply it to our patients Subverted by BigPharma and Disease mongers No RCTs have been performed Has been shown not work in real world

30 Patient Based Medicine (PBM) Unit of Care is Patient Goals set with patient Outcomes aligned with those goals Process of care is secondary UNIFORMITY is BAD MAXIMISE variability within the limits of the evidence base to meet the range of patient directed goals

31 Doctor s Role in PBC Listen Help set Goals Apply knowledge of Evidence to achieve Goals State what is and what is not negotiable Support decision making Individualise process of care, be flexible Use resources wisely Maintain the doctor-patient relationship esp in those with chronic disease

32 Care of multi-morbidity 1.Patient preference Domain 2.Evidence Domain 3. Prognosis Domain 4. Feasibility Domain 5. Therapies and Care Plan Domain

33 Credulity Scale Cynical Nihilist Sceptical Suggestible Gullible

34 Emotional Wellbeing Scale Pessimist Gloomy Satisfied Optimist

35 Reasons to be Optimistic Demise of EBM Too Much Medicine / Choosing Wisely etc Re-affirmation of the Patient supremacy Improved knowledge Precision Medicine Return of the Generalist Vastly improved health and happiness of our elders.

36 Optimist Scale Optimist Cynical Sceptical Suggestible Gullible Pessimist

37 Optimist Scale: Where are you? Optimist Cynical Sceptical Suggestible Gullible Pessimist

38 As serious illness is lived, evidence based guidelines may become irrelevant, absurd or even harmful Greenhalgh BMJ 2014