Monday, 1 October 2018

Treatments, tested

The other day, Xavier Bonfill and Iain Chalmers presented the Catalan edition of the book Testing Treatments. Better Research for Better Healthcare. This caught my attention and after 12 years of delay, I was motivated to read the work. It’s necessary to clarify that in 2006, the year of its first edition; I was a hospital CEO and had neither the head nor the time for this. Maybe one day we will have to talk about what the executives read. Be that as it may, this text is considered one of those that have laid the foundations of modern clinical management, which concentrates its focus on effectiveness, a goal as coveted as it is difficult (1).

Journalist Nick Ross, in the presentation of the first edition of the book, wrote: "This book is good for health; it shines light on the mysteries of how decisions about life and death are made. It goes to show how these criteria are generally lacking and it challenges doctors from around the world to change their ways.” On the other hand, Ben Goldacre, in the prologue of the second edition (2011), provides a really interesting quote: "The true purpose of the scientific method is to make sure that nature doesn’t mislead us into thinking that we know something that we don’t really know".

Many clinical practices don’t have consistent support from the evidence

As the authors point out, doctors who wish to innovate (especially, but not only, in the field of surgery) find it easier, after developing some more or less credible theory, to implement a new technique than to develop a clinical trial, because, if they do, they will have to write cumbersome protocols that inevitably, will need the approval of the research ethics committee of their institution. Many doctors tend therefore, to trust more in their experience than in the evidence. This much implanted dynamic, impoverishes medicine because it prevents accumulation of knowledge and therefore, ill people are forced to rely on their doctor's intuition instead of being able to decide from contrasted information.

The importance of systematic reviews

Systematic reviews and meta-analyzes are becoming increasingly important. Many doctors read them to keep abreast of developments and then use them to update treatments and guidelines. For this reason, it’s essential that the reviews are made with the least possible bias, but this is a task of great complexity especially because some researchers, when they feel disappointed by the results obtained, don’t publish them. Pharmaceutical companies on the other hand, can hide studies that are not favourable to them, while scientific journals with their editorial selection, also contribute to the difficulties in obtaining broad and quality reviews. For all these reasons, the authors recommend that all research projects are obliged to begin and end with systematic reviews that not only show, clearly, the accumulated experience in that area, but are also able to explain the new value offered by their proposal.

Some alarming data

The book makes a very illustrative and well-argued review of the lights and shadows of the history of biomedical research, while providing food for thought and advice on how to practice medicine with the least possible uncertainty. There are, however, two alarming facts that I want to highlight: a) according to Ben Goldacre, in the prologue of the second edition, the studies financed by industry are four times more likely to obtain a positive result than independent trials. Goldacre says that launching a new drug can cost up to $800 million and with these investment volumes the ideals of impartiality can fail; b) according to the authors themselves, only 17% of the medicines advertised in medical journals are supported by research of proven quality.

I would like to finish this review with one of the conclusions of the book: "It’s fundamental to consult the scientific evidence over and over again, review it critically and systematically before starting a new investigation and in the same way, interpreting the new results in light of the updated systematic reviews".

(1) In my opinion, there are three other books that fit in the category of having contributed decidedly to generate the conceptual foundations of value-based clinical management: a) Redefining Health Care. Creating Value-Based Competition on Results by Michael Porter & Elizabeth Olmsted Teisberg (2006), b) Over treated. Why too much medicine is making us sicker and poorer by Shannon Brownlee (2008) and c) Tracking Medicine. A Researcher's Quest to Understand Health Care by John Wennberg (2010).

Jordi Varela

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