Korenstein comments about the new recommendations on breast cancer screening from the Canadian Task Force on Preventive Health Care, which serve as a model for the important role of guidelines in ...promoting value in health care. The main task force guideline recommendations - against screening in women in their 40s and for screening women aged 50 to 74 with mammography every 2 to 3 years - encourage value through avoidance of nonbeneficial care and are similar to recommendations from the 2011 task force guidelines and from other international organizations. However there are implementation challenges including time, individualized risk assessment and balancing potential screening benefits and harms are complex and cultural challenges to truly balanced decisions.
Summary Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of ...delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
Objective To examine the association between the presence of individual principal investigators’ financial ties to the manufacturer of the study drug and the trial’s outcomes after accounting for ...source of research funding.Design Cross sectional study of randomized controlled trials (RCTs).Setting Studies published in “core clinical” journals, as identified by Medline, between 1 January 2013 and 31 December 2013.Participants Random sample of RCTs focused on drug efficacy.Main outcome measure Association between financial ties of principal investigators and study outcome.Results A total of 190 papers describing 195 studies met inclusion criteria. Financial ties between principal investigators and the pharmaceutical industry were present in 132 (67.7%) studies. Of 397 principal investigators, 231 (58%) had financial ties and 166 (42%) did not. Of all principal investigators, 156 (39%) reported advisor/consultancy payments, 81 (20%) reported speakers’ fees, 81 (20%) reported unspecified financial ties, 52 (13%) reported honorariums, 52 (13%) reported employee relationships, 52 (13%) reported travel fees, 41 (10%) reported stock ownership, and 20 (5%) reported having a patent related to the study drug. The prevalence of financial ties of principal investigators was 76% (103/136) among positive studies and 49% (29/59) among negative studies. In unadjusted analyses, the presence of a financial tie was associated with a positive study outcome (odds ratio 3.23, 95% confidence interval 1.7 to 6.1). In the primary multivariate analysis, a financial tie was significantly associated with positive RCT outcome after adjustment for the study funding source (odds ratio 3.57 (1.7 to 7.7). The secondary analysis controlled for additional RCT characteristics such as study phase, sample size, country of first authors, specialty, trial registration, study design, type of analysis, comparator, and outcome measure. These characteristics did not appreciably affect the relation between financial ties and study outcomes (odds ratio 3.37, 1.4 to 7.9).Conclusions Financial ties of principal investigators were independently associated with positive clinical trial results. These findings may be suggestive of bias in the evidence base.
Accurate diagnosis is essential to proper patient care.
To explore practitioner understanding of diagnostic reasoning.
In this survey study, 723 practitioners at outpatient clinics in 8 US states ...were asked to estimate the probability of disease for 4 scenarios common in primary care (pneumonia, cardiac ischemia, breast cancer screening, and urinary tract infection) and the association of positive and negative test results with disease probability from June 1, 2018, to November 26, 2019. Of these practitioners, 585 responded to the survey, and 553 answered all of the questions. An expert panel developed the survey and determined correct responses based on literature review.
A total of 553 (290 resident physicians, 202 attending physicians, and 61 nurse practitioners and physician assistants) of 723 practitioners (76.5%) fully completed the survey (median age, 32 years; interquartile range, 29-44 years; 293 female 53.0%; 296 53.5% White). Pretest probability was overestimated in all scenarios. Probabilities of disease after positive results were overestimated as follows: pneumonia after positive radiology results, 95% (evidence range, 46%-65%; comparison P < .001); breast cancer after positive mammography results, 50% (evidence range, 3%-9%; P < .001); cardiac ischemia after positive stress test result, 70% (evidence range, 2%-11%; P < .001); and urinary tract infection after positive urine culture result, 80% (evidence range, 0%-8.3%; P < .001). Overestimates of probability of disease with negative results were also observed as follows: pneumonia after negative radiography results, 50% (evidence range, 10%-19%; P < .001); breast cancer after negative mammography results, 5% (evidence range, <0.05%; P < .001); cardiac ischemia after negative stress test result, 5% (evidence range, 0.43%-2.5%; P < .001); and urinary tract infection after negative urine culture result, 5% (evidence range, 0%-0.11%; P < .001). Probability adjustments in response to test results varied from accurate to overestimates of risk by type of test (imputed median positive and negative likelihood ratios LRs for practitioners for chest radiography for pneumonia: positive LR, 4.8; evidence, 2.6; negative LR, 0.3; evidence, 0.3; mammography for breast cancer: positive LR, 44.3; evidence range, 13.0-33.0; negative LR, 1.0; evidence range, 0.05-0.24; exercise stress test for cardiac ischemia: positive LR, 21.0; evidence range, 2.0-2.7; negative LR, 0.6; evidence range, 0.5-0.6; urine culture for urinary tract infection: positive LR, 9.0; evidence, 9.0; negative LR, 0.1; evidence, 0.1).
This survey study suggests that for common diseases and tests, practitioners overestimate the probability of disease before and after testing. Pretest probability was overestimated in all scenarios, whereas adjustment in probability after a positive or negative result varied by test. Widespread overestimates of the probability of disease likely contribute to overdiagnosis and overuse.
The high cost of cancer care worldwide is largely attributable to rising drugs prices. Despite their high costs and potential toxic effects, anticancer treatments could be subject to overuse, which ...is defined as the provision of medical services that are more likely to harm than to benefit a patient. We found 30 studies documenting medication overuse in cancer, which included 16 examples of supportive medication overuse and 17 examples of antineoplastic medication overuse in oncology. Few specific agents have been assessed, and no studies investigated overuse of the most toxic or expensive medications currently used in cancer treatment. Although financial, psychological, or physical harms of medication overuse in cancer could be substantial, there is little published evidence addressing these harms, so their magnitude is unclear. Further research is needed to better quantify medication overuse, understand its implications, and help protect patients and the health-care system from overuse.
Access to rapid and accurate detection of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA is essential for controlling the current global pandemic of coronavirus disease 2019. In ...this study, the use of oral rinses (ORs) and posterior oropharyngeal saliva as an alternative to swab collection methods from symptomatic and asymptomatic health care workers for the detection of SARS-CoV-2 RNA by RT-PCR was evaluated. For saliva samples, the overall agreement with oropharyngeal swabs was 93% (Ƙ = 0.84), with a sensitivity of 96.7% (95% CI, 83.3%–99.8%). The agreement between saliva and nasopharyngeal swabs was 97.7% (Ƙ = 0.93), with a sensitivity of 94.1% (95% CI, 73.0%–99.7%). ORs were compared with nasopharyngeal swabs only, with an overall agreement of 85.7% (Ƙ = 0.65), and a sensitivity of 63% (95% CI, 46.6%–77.8%). The agreement between a laboratory-developed test based on the CDC RT-PCR and two commercial assays, the Xpert Xpress SARS-CoV-2 and the Cobas SARS-CoV-2, was also evaluated. The overall agreement was >90%. Finally, SARS-CoV-2 RNA in saliva samples was shown to be stable, with no changes in viral loads over 24 hours at both room temperature and 4°C. Although the dilution of SARS-CoV-2 in ORs precluded its acceptability as a sample type, posterior oropharyngeal saliva was an acceptable alternative sample type for SARS-CoV-2 RNA detection.
Advocacy is a core component of medical professionalism. It is unclear how educators can best prepare trainees for this professional obligation. We sought to assess medical students' attitudes toward ...advocacy, including activities and issues of interest, and to determine congruence with professional obligations.
A cross-sectional, web-based survey probed U.S. medical students' attitudes around 7 medical issues (e.g. nutrition/obesity, addiction) and 11 determinants of health (e.g. housing, transportation). Descriptive statistics, Kruskal-Wallis tests, and regression analysis investigated associations with demographic characteristics.
Of 240 students completing the survey, 53% were female; most were white (62%) or Asian (28%). Most agreed it is very important that physicians encourage medical organizations to advocate for public health (76%) and provide health-related expertise to the community (57%). More participants rated advocacy for medical issues as very important, compared to issues with indirect connections to health (p < 0.001). Generally, liberals and non-whites were likelier than others to value advocacy.
Medical students reported strong interest in advocacy, particularly around health issues, consistent with professional standards. Many attitudes were associated with political affiliation and race. To optimize future physician advocacy, educators should provide opportunities for learning and engagement in issues of interest.
Primary care clinicians, who are increasingly responsible for caring for the growing population of cancer survivors, may be unfamiliar with appropriate cancer surveillance strategies. Clinical ...practice guidelines can inform cancer follow-up care and surveillance testing. Vague recommendations and inconsistencies among guidelines can lead to overuse and underuse of health care resources and have a negative impact on cost and quality of survivorship care.
To examine the specificity and consistency of recommendations for surveillance after active treatment across cancer guidelines.
Retrospective cross-sectional analysis of national cancer guidelines from North America and Europe published since 2010 addressing posttreatment care for survivors of the 9 most common cancers. We categorized surveillance modalities into history and physical examinations, tumor markers, diagnostic procedures (eg, colonoscopy), and imaging. Within each guideline, we classified individual recommendations into 5 categories: (1) risk-based recommendation, (2) recommendation for surveillance, (3) addressed but no clear recommendation, (4) recommendation against surveillance, or (5) cases in which surveillance was not addressed. We reviewed each surveillance recommendation for frequency and a stop date, evaluated consistency among guidelines, and analyzed associations between the organizations proposing the guidelines and recommendation characteristics.
Description of guideline recommendations for cancer surveillance.
We identified 41 guidelines published between January 1, 2010, and March 1, 2016. Eighty-five percent of guidelines (35) were from professional organizations. Ambiguous recommendations (ie, modality not discussed or discussed without a clear recommendation) were present in 83% of guidelines (34), and 44% (18) recommended against at least 1 test. European guidelines were more likely than North American guidelines to contain ambiguous recommendations (100% vs 68%; P < .01). Recommendations commonly specified testing frequency (from 88% 14 of 16 for tumor markers to 92% 24 of 26 for procedures and/or imaging) but infrequently provided a definitive stop time. Cross-sectional imaging recommendations varied among guidelines for each cancer. For example, among breast cancer guidelines, surveillance computed tomographic scans were recommended against in 2, discussed without a clear recommendation in 1, and not addressed in 3 guidelines.
Guidelines addressing the care of cancer survivors have low specificity and consistency. As guidelines continue to be revised, developers should clarify recommendations with simple, nonambiguous, definitive language for or against the use of specific tests to optimize care quality and resource utilization.
New dissemination methods are needed to engage physicians in evidence-based continuing medical education (CME).
To examine the effectiveness of social media in engaging physicians in ...non-industry-sponsored CME.
We tested the effect of different media platforms (e-mail, Facebook, paid Facebook and Twitter), CME topics, and different "hooks" (e.g., Q&A, clinical pearl and best evidence) on driving clicks to a landing site featuring non-industry sponsored CME. We modelled the effects of social media platform, CME topic, and hook using negative binomial regression on clicks to a single landing site. We used clicks to landing site adjusted for exposure and message number to calculate rate ratios. To understand how physicians interact with CME content on social media, we also conducted interviews with 10 physicians.
The National Physicians Alliance (NPA) membership.
NPA e-mail recipients, Facebook followers and friends, and Twitter followers.
Clicks to the NPA's CME landing site.
On average, 4,544 recipients received each message. Messages generated a total of 592 clicks to the landing site, for a rate of 5.4 clicks per 1000 recipients exposed. There were 5.4 clicks from e-mail, 11.9 clicks from Facebook, 5.5 clicks from paid Facebook, and 6.9 clicks from Twitter to the landing site for 1000 physicians exposed to each of 4 selected CME modules. A Facebook post generated 2.3x as many clicks to the landing site as did an e-mail after controlling for participant exposure, hook type and CME topic (p<0.001). Twitter posts (p = 0.13) and paid Facebook posts (p = 0.06) were not statistically different from e-mail in generating clicks to the landing site. Use of different hooks to engage physicians had no impact on clicks to the landing site. Interviews with physicians suggested that social media might not be a preferred vehicle for disseminating CME.
Social media has a modest impact on driving traffic to evidence-based CME options. Facebook had a superior effect on driving physician web traffic to evidence-based CME compared to other social media platforms and email.
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