Live data from Hacker News

The Rise and Fall of Evidence Based Medicine (1998) [pdf]

researchgate.net

111–120 of 136 posts

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#111

Earlier quoted context omitted.

> Later, somebody did that study: https://www.bmj.com/content/363/bmj.k5094 and found that parachutes made no difference, but it is not applicable to any real world case where you would use a parachute. As a physician you are likely aware, but for anyone reading who isn’t: this paper is from the Christmas issue of the BMJ, which publishes “joke” studies. It’s not really meant to be taken seriously in any way.

But there is a serious point to be made, of course. This study involved jumping from stationary airplanes on the ground, which negates the whole point of a parachute (and hence, the control group survived just fine). It therefore "proved" that you don't need a parachute when jumping from an airplane, on the assumption that the results extrapolate to higher altitudes. Nonsense, of course. But then there's a lot of ran…

Yes, like all good satire there is a serious point behind it, but I think the way the GP referenced the two articles doesn’t make it clear that it’s a satire as opposed to a real example of poor/flawed EBM.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#112
post #67

Earlier quoted context omitted.

Yes, it's 'curious' how people with a sense of basic decency get 'combative' when the Alternative Medicine Industry lies to them to sell useless treatments for diseases that could actually be improved by real medicine. It really is odd how that works, isn't it?

homeopathic medicine is clearly marked as such, do you disagree on this point? anyone who complains about it who doesn't have at least as strong a crusade against crap like phenylephrine is a hypocrite

> homeopathic medicine is clearly marked as such, do you disagree on this point?

I disagree that it qualifies as medicine.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#113

Evidence Based Medicine is one of those things that is a good thing, but was pushed so hard by its proponents that it ended up overemphasizing a particular kind of study as the only real way to know things in medicine. Yes, absolutely, medicine should be evidence based. Yes, large randomized, double blind, placebo controlled studies provide a lot of information. However, there are limitations with these kinds of stud…

Another problem I stumbled over is how evidence based medicine makes it increasingly more difficult to deviate from established routines and modalities. Long time existing methodologies will by nature of having been around longer have a larger pile of evidence backing up their efficacy, compared to a new method, that might perform better, but has limited patient study data to back that up. I've seen how this stalls uptake of otherwise evident (non patient trial data based) improvements. I even seems that some manufacturers are very well aware of this, and are thus using their fortunate position of having to only incrementally improve methods at very low R&D cost.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#114

Earlier quoted context omitted.

Estrogen/progesterone and testosterone are not exclusively female/male hormones. Testosterone may boost sex drive and increase muscle mass, as well as provide some psychological benefit in women. Estrogen is the most important regulator of bone health in both men and women. There are people with estrogen insensitivity syndrome, both men and women, and from all reports they are having an extremely uncool time: https:/…

Yes but why on earth would testosterone be part of HRT for menopause? The point is to replace what’s missing and causing symptoms. Menopause =/= estrogen insensitivity.

Testosterone levels are drastically lowered in women going through menopause.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#115

Earlier quoted context omitted.

All adult patient populations: those without a history of cardiovascular events, and those with. Baseline risk is something like ~35% for men, and ~20% women. Time point is from 50 to 75 years of age. Statins -- at most -- reduce your absolute risk from 35% to 33% (for men) and from 20% to 18% (for women). If you do not smoke, your absolute risk drops by ~7%, from 35% to 28%. If you're diabetic, your risk jumps an ab…

As stated thennt is from 2013, many statin trials have come out since. 2% diabetes is overstated as in link 1 except you discount it because of declared disclosures despite the fact that it’s one of the most highly cited papers on the subject in the last 10 years and the study was a review. You also discount a well respected guideline on lipids out of principle. Then you cite unrelated data from 2006 as a good refere…

I cannot make it anymore clearer: statins reduce your absolute risk of mortality by at most 2%; not smoking reduces your absolute risk by 7%. Statins provide meager benefit for the associated risks. It does not take an expert to do math.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#116

Earlier quoted context omitted.

Generally, you read the papers for their methodology and their data — not for the author commentary; and then make up your own mind. One man’s “benefits of statins for primary prevention” is another’s “the benefits are too meager to be notable.” Please provide me literature from a reputable publication (viz. the AHA, Cochrane, or the New England Journal of Medicine), that has not been funded by a pharmaceutical compa…

So every link I provided give you a risk of MACE. Reversal of atherosclerosis is not the outcome measure we care about lol. Certainly not lowering coronary calcium which is not possible. You’re literally making this up… Statins work amazingly not just for LDL reduction but plaque stabilization. As an aside a 2% ARR is huge, it means the number needed to treat is 50 to save a life. For something with next to no seriou…

Then we are at an uncrossable philosophical chasm.

I don’t consider 2% ARR huge — especially when the risks of side-effects have been down-played. We can argue about this all we want, but it’s no longer a matter of fact, but of opinion and values.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#117
post #108

Earlier quoted context omitted.

Generally, you read the papers for their methodology and their data — not for the author commentary; and then make up your own mind. One man’s “benefits of statins for primary prevention” is another’s “the benefits are too meager to be notable.” Please provide me literature from a reputable publication (viz. the AHA, Cochrane, or the New England Journal of Medicine), that has not been funded by a pharmaceutical compa…

> Generally, you read the papers for their methodology and their data — not for the author commentary; and then make up your own mind. I'd say that generally it's advisable to take both into consideration given that in most cases the author of a paper likely has more domain expertise than you in that specific area. Not always, obviously, and not to the exclusion of an outside objective analysis of their data and resu…

> I'd say that generally it's advisable to take both into consideration given that in most cases the author of a paper likely has more domain expertise than you in that specific area. Not always, obviously, and not to the exclusion of an outside objective analysis of their data and results, but it's certainly more informative than referring someone to a page from a study with no additional context.

I do not agree. I do not have the time to elaborate further.

————

> I get where you're coming from here, but it's kind of silly. And the question becomes where do you draw the line? Is a meta-analysis of a large group of studies each of which has been supported at least in part by funding from a pharmaceutical company guilty by association? That aside, the structure of research funding with regards to pharmaceuticals (at least in the US so far as I'm aware) makes the likelihood of conducting any long term, large scale study without receiving any funding from a pharmaceutical company vanishingly small. There have certainly been issues with studies funded and conducted by those companies, but that doesn't mean that all studies funded by them are instantly invalid. Nor does it mean that it's impossible to conduct a study that has received their funding without compromising its integrity. It is entirely possible to take sufficient measures to isolate those companies from the actual process and analysis of the research.

Again, I do not agree. These are matters of values, and no arguments can be made for what we innately value. I draw a nuanced line based on my values, that I have tried to express here; but making it finer and finer will serve no purpose but as fuel for disagreement — because it is wholly subjective.

Possibility is not actuality. Most researchers are not a Platonic ideal: perfectly noble and virtuous and vigilant. They are real people: lazy, prone to error, requiring money to survive, self-interest at the very forefront.

I will not call your viewpoint naive, but it’s something that can only be formed when one’s exposure to this field is limited to papers and doctor’s visits.

> Why that number? And why that number in two very different contexts? Regardless, statins have been show in numerous studies to be highly effective.

Because 2% ARR is the highest change I’ve seen in any statin experiment — in either context. I do not consider one out of every fifty people being saved by a statin significant, or my definition of “highly effective.”

> It appears that the evidence in support of the use of statins is quite overwhelming.

My patience for reiterating this point is gone: relative changes are not absolute changes.

A starting risk profile of 2.25%, reduced to 1.25%, will have been reduced an absolute 1%, but a relative 44%.

This is why you read the methodology, and not the authors’ interpretation of their own data.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#118
post #74

Earlier quoted context omitted.

All interventions that don’t require a patient being in a coma first requires patient compliance . Diet and lifestyle are nearly impossible to address from the perspective of the Dr, as they require the patient to want to and be willing to change foundational elements of their life . Unless the patient comes to you requesting that, good luck. Many will get actively angry if you mention even obvious and severe issues…

treating obesity like a lifestyle condition and not a bonafide disease and dismissing patients with vague recommendations to eat less and exercise more is ignoring the overwhelming body of evidence supporting that behavioral interventions don't work and that the body has strong homeostatic mechanisms which fight efforts to move the weight set point. i can only hope that you're not a doctor

So what do you propose?

Because what you wrote sounds a lot like ‘it’s unsolvable’, which is clearly not true either.

Gastric restriction is an extreme solution, and rarely that effective long term.

Pharmacological is often fraught with serious side effects and also has poor long term efficacy.

In my experience it’s usually psychiatric and environmental, which is why it’s hard to tackle, and nearly impossible without patient willingness to change - and that’s always hard.

Even if willing to change, being able to change is often very difficult too as it’s rarely one factor.

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#119

Earlier quoted context omitted.

So every link I provided give you a risk of MACE. Reversal of atherosclerosis is not the outcome measure we care about lol. Certainly not lowering coronary calcium which is not possible. You’re literally making this up… Statins work amazingly not just for LDL reduction but plaque stabilization. As an aside a 2% ARR is huge, it means the number needed to treat is 50 to save a life. For something with next to no seriou…

Then we are at an uncrossable philosophical chasm. I don’t consider 2% ARR huge — especially when the risks of side-effects have been down-played. We can argue about this all we want, but it’s no longer a matter of fact, but of opinion and values.

You seem to be misunderstanding how evidence works, it is not about “what you consider” and is entirely based on fact. We also don’t talk ARR in isolation when we decide on interventions, it’s NNT vs NNH and considering the specific risk being reduced and the specific harm.

I’ll use your 2% ARR for death although there are better numbers in different patient populations.

In other words: Statins will save 1 life for every 50 patients treated and prevent 1 in ~20-40 non-fatal cardiac events, a medically significant result period. The NNH is > 100, and the harm is a self-limiting myopathy (and a possible risk of accelerated diabetes-onset in observational studies, that is still outweighed by the reduction in all-cause mortality and MACE).

The evidence is unequivocal that the benefits far outweigh the harms.

Separately, you have a personal choice to take/not take any treatment, and you may personally feel treating 50 people to save 1 life is not worth it for you, because you subjectively feel the numbers don’t fit your personal risk/benefit model. This is where you are saying 2% ARR is insignificant to you but this says nothing about the evidence or rationale behind the treatment.

> risks of side-effects have been down-played.

Except every study looking at side-effects has shown they were overstated in the initial trial.

“The most severe complication of SI is discontinuation of effective cholesterol-lowering treatment in patients who, by virtue of their CVD risk and cholesterol level, might otherwise benefit.”

https://www.sciencedirect.com/science/article/abs/pii/S00219...

Re: The Rise and Fall of Evidence Based Medicine (1998) [pdf]

#120

Earlier quoted context omitted.

Then we are at an uncrossable philosophical chasm. I don’t consider 2% ARR huge — especially when the risks of side-effects have been down-played. We can argue about this all we want, but it’s no longer a matter of fact, but of opinion and values.

You seem to be misunderstanding how evidence works, it is not about “what you consider” and is entirely based on fact. We also don’t talk ARR in isolation when we decide on interventions, it’s NNT vs NNH and considering the specific risk being reduced and the specific harm. I’ll use your 2% ARR for death although there are better numbers in different patient populations. In other words: Statins will save 1 life for e…

This conversation is going in circles.

Linked study equivocating on the overstatement of statin side-effects has the first author as a pharmaceutical consultant (you do not see this as a problem, I do).

2% ARR is meager in relation to lifestyle changes that can account for 3x-15x the in ARR compared to statins (you do not see this as a problem, I do).

Those are the facts. How you interpret them is subjective.

All of the money and manpower thrown into statins, could have been thrown into smoking cessation programs or preventing onset of type 2 diabetes. This is an opinion.

Saving 1 life for every 50 patients, at the cost of untold resources, instead of saving 6-30 for every 50 is myopic. This is an opinion.

Medical significance is an opinion. The determination of significance is a subjective interpretation. This is not a "this idea concurs with my sentiments, so I will say it is so. Period." This is math. Statistical interpretation is an opinion. The difference in statin efficacy vs. lifestyle changes is a quantifiable fact. The difference is 3-15x. To take a statistical finding without incorporating it into the larger context is poor practice, bordering on deception (the former is a fact, the latter is an opinion).

Here are 50 people aged 50 y.o. from the general population:

OOOOO_OOOOO | OOOOO_OOOOO | OOOOO_OOOOO | OOOOO_OOOOO | OOOOO_OOOOO

Here is the same group of people after 25 years (14 have died due to CVD-related mortality):

XXXXX_XXXXX | XXXXO_OOOOO | OOOOO_OOOOO | OOOOO_OOOOO | OOOOO_OOOOO

Here is the same group of people after 25 years, but they were on statins:

XXXXX_XXXXX | XXXOO_OOOOO | OOOOO_OOOOO | OOOOO_OOOOO | OOOOO_OOOOO

Here is the same group of people after 25 years, but instead of statins, the smokers ceased smoking:

XXXXX_XXXXX | OOOOO_OOOOO | OOOOO_OOOOO | OOOOO_OOOOO | OOOOO_OOOOO

Here is the same group of people after 25 years, but instead of a treatment, all of them developed diabetes:

XXXXX_XXXXX | XXXXX_XXXXX | XXXXX_XXXXX | XXXOO_OOOOO | OOOOO_OOOOO

Post reply on HN