No evidence that N95 respirators are better than surgical masks

From NinjaCat14 on  Deviant Art  I can't make this stuff up!

From NinjaCat14 on Deviant Art
I can't make this stuff up!

Specialized technologies are always sexier than their basic alternatives.

We often think that new and complicated is better. Or that if something is more expensive if must work better, right? 

One small trial found that a more expensive placebo was much more effective than the cheap one in Parkinson's patients. There is a lot of interesting research around how cost influences thinking and choice, and much of it is applied by manufacturers to influence their markets (see for example: Relative thinking in consumer choice between differentiated goods and services and its implications for business strategy).

Sometimes we think again about something that is not new, but an existing technology or process that we just use by habit, having assumed for years that it was better than the alternatives. Rarely are these things scrutinized, but sometimes when they are, we find out we are  "all wrong." For example, we have long assumed that acetaminophen is helpful for lower back pain but a meta-analysis in the BMJ in March 2015 found this is not the case.

In a recent Canadian Medical Association Journal (CMAJ) article, Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis, we learned that there really is not a lot of clinical research that supports the effectiveness of N95 masks. In the lab, yes, surrogate markers suggest the N95 masks could be "better" than normal surgical masks, but the data in practice is so lacking. 

Smith et al. concluded that "Although N95 respirators appeared to have a protective advantage over surgical masks in laboratory settings, our meta-analysis showed that there were insufficient data to determine definitively whether N95 respirators are superior to surgical masks in protecting health care workers against transmissible acute respiratory infections in clinical settings."

Of course 'insufficient data' doesn't mean we should abandon these masks. While I will still wear N95s for seeing TB patients and for performing high risk interventions on patients with influenza like illness, I now begin to wonder if this is really necessary.

There are so many 'fancy' technologies that we have discovered are no better than the old ones, and our knowledge of the waste, cost, and sometimes harms associated with them makes it hard to  not carefully scrutinize every 'new alternative' and 'innovation.' 

As I head to Toronto for a meeting of the CMA's Joule Innovation Council this week, I must laugh a bit. I imagine my experience in critical review of medical literature and knowledge of the harms from overtesting/treating/diagnosis, will make me one of the toughest judges of our colleagues' submissions! We are reviewing grant proposals for development of innovations from Canadian physicians.

I hope that with this privilege, I can be both enthusiastic and measured in my assessments, though I won't be surprised if I'm one of the more, uh 'fiery,' of the dragons in the den. With the collective wisdom of the group, I'm certain we will support some elegant, thoughtful, and effective innovations to make a positive difference for patients and health care systems.

Source: http://www.ncbi.nlm.nih.gov/pubmed/2695252...

PODCAST: Questioning Medicine - Statin showdown

When it comes to statin dosing, um, what is the right dose?

Drs Joe Weatherly and Andrew Buelt of Questioning Medicine tackle this question as they review the evidence on statin dosing in their latest podcast. They also do a nice shout out to Less is More Med, but get into dangerous territory by bragging to a Canadian about their hockey team.*

Anyway, they do know a lot more about statins than they know about hockey; this is the fourth in a series of 5 shows devoted to critical appraisal of statin studies. The whole collection is here at Podomatic. 

The pair also run a blog at MedPage Today, Questioning Medicine; though less frequently updated, their posts are great at tackling some of the assumptions we make.

Kayexelate to lower potassium? Maybe not that effective. Pelvic Exams? Probably unnecessary and likely harmful. What Joe and Andrew write always provides a gentle reminder to readers that our thinking "it might not help but it probably doesn't hurt" is off-base; there's plenty of evidence to back a change in practice for the better.

Like their style? You'll also love the other groups that act as Evidence-Based Medicine champions and 'medical mythbusters,' providing sharp (and sometimes hilarious) critical reviews of the latest evidence.

 

* While Tampa Bay did pretty well this NHL Playoff season, these guys will have to be careful about bragging about their success, given that the Lightening's roster is primary comprised of Canadian players. 

Source: http://questioningmed40708.podomatic.com/e...

I love Healthcare Triage! VIDEO: Malpractice, Healthcare Costs, and Tort Reform

Dr Aaron Carroll (@aaronecarroll) & Co. are amazing!

Healthcare Triage (@HCTriage) has a YouTube channel that hosts a range of videos, most of which pertain to the "Less is More in Medicine" movement. The Less is More blog has featured their work before, 1) when Healthcare Triage did a video about Choosing Wisely, and 2) when Dr Carroll wrote Why Survival Rate Is Not the Best Way to Judge Cancer Spending for Upshot in the NY Times. In early June, they posted another great video, busting some major medico-legal myths.

One of the main excuses physicians make for ordering too many tests and treatments is that they have to practice defensive medicine. You must 'cover your ass' (CYA) to ensure nothing is missed, lest you face a horrible lawsuit. Physicians pay a ransom to malpractice insurance in order to help protect their reputation (and earnings) should a case come forward.

Many frivolous lawsuits exist and a lot of poor care is not legally pursued. Physicians think that tort reform will solve everything. Not so. Watch the video to learn more:

Source: https://www.youtube.com/watch?v=sK-E_d1MGt...

Other Blogs: Less Is More | An index of evidence-based, “less-medical” patient care

More "Less is More"!

Dr Bill Cayley Jr has started a Wordpress Blog, "Less is More EBM" to review studies that explore situations in which less involved/invasive/expensive/difficult/novel/etc. care is actually best for patients.

He writes, "This index is currently a personal (and extremely part-time!) project aiming to catalog literature documenting when “less is more” in a searchable and accessible format." It has just started, but there are already insights on papers about overuse of arthroscopy, the best treatment for paediatric upper respiratory infection, and creative solutions for low resource areas (eg. mosquito nets instead of mesh for hernia repair).

It's great to see interest booming. More people are writing books and blogs, talking at conferences, changing the care they deliver, and asking questions of their health care provider. The movement – still known by many names, a few of which are highlighted in the glossary – is growing!

If you are particularly interested in blogs, look at the left sidebar column, and under 'Similar Blogs' you'll find others writing about similar issues as you'll find on this site. Check 'em out!

Source: https://lessismoreebm.wordpress.com/

BMJ Blogs: Six proposals for EBM’s future

Dr Paul Glasziou is a Professor of Evidence-Based Medicine at Bond University in Australia. He speaks and writes mainly about the translation of health research into clinical practice.

His latest contribution to the BMJ Blog is a look at the future of evidence-based medicine (EBM). As its era fades into another, it becomes apparent that there is still a huge gap between what research tells us and what doctors and patients wind up doing.

Sometimes the known evidence is biased, of poor quality, or doesn't actually have any relevance for our patient. Sometimes, we have strong evidence about what is clinically 'correct' but we have forgotten to remember that each patient is an individual, with unique goals and life circumstances. Sometimes, we get so caught up in chasing the potential benefits of something that we fail to realize it could be causing more harm than good.

Read Dr Glaszious' Six Proposals for EBM's future, as he tackles these tough issues and helps to guide us back to a place where research improves care.

Source: http://blogs.bmj.com/ce/2015/03/27/six-pro...

Update: POEMs help identify clinical practices for the Choosing Wisely Campaign

Update: Grad et al's paper is now published! View the full text: Patient-Oriented Evidence that Matters (POEMs) Suggest Potential Clinical Topics for the Choosing WiselyCampaign in JABFM.

[this blog post below was originally published Nov 24, 2014]


It can be challenging to cultivate topics for the Choosing Wisely Campaign; Montréal family physician and researcher Dr. Roland Grad (bio) and his group have found a unique way to harness an existing tool to do so easily.

Dr Grad presented a poster at the Family Medicine Forum (FMF) indicating one way forward could employ physician ratings of Patient-Oriented Evidence that Matters (POEMs).

POEMs are short summaries of relevant and valid information for clinicians. These are free for Canadian Medical Association (CMA) members (login to cma.ca, click on your name, and go to the Manage Newsletters section) and are basically quick reads with commentary on recent clinical trials, systematic reviews, etc. [Non-CMA members can go to Essential Evidence Plus]

Grad, Pluye, Shulha and Tang focused on one item on the validated questionnaire used by physicians to evaluate POEMs, which asked whether the POEM helped the practitioner in ‘avoiding an unnecessary diagnostic test or treatment’.

They identified the top 20 POEMs in each of two years most commonly associated with helping avoid unnecessary tests or treatment. Interestingly, only 11 of the 40 POEMs had a corresponding item on the Choosing Wisely master list.

[short version: there's a huge collection of already identified practice-changing recommendations just ripe for the adding to a campaign like Choosing Wisely!]

Their process provides an easy way to gather possible topics for future Choosing Wisely lists and could aid in the expert panel approach.

The group's paper is now in the Journal of the American Board of Family Medicine.

CONFERENCE: ISDM/ISEHC2015: Bringing Evidence-Based Practice and Shared Decision-Making Together

What could be better than a conference combining evidence-based practice (EBM) and shared decision making (SDM)!? 

A conference combining EBM and SDM... in Australia!!

That's right, July 19-22, the University of Sydney will be hosting the joint international shared decision-making (ISDM) and International Society for Evidence Based Health Care (ISEHC) conference.

Drs Paul Glasziou (@PaulGlasziou) and Lyndal Trevena (@LyndalTrevena) host, with keynote speeches from Drs Victor Montori (@VMontori), Alexandra Barratt (U of Sydney, organizing committee of Preventing Overdiagnosis), and Sharon Strauss (U of Toronto).

Submit an abstract today! Early bird registration will open soon, and close April 17, 2015. Check out the website and subscribe to their email list so you know as soon as registration opens.

 

Find out about other conferences and events on the subject of Overdiagnosis, the application of evidence and shared decision-making, and Less is More in Medicine.

The one chart you need to (begin to) understand any health study

Jullia Belluz, common-sense and evidence-oriented journalist (known to me from her great "Science-ish" Maclean's column) and Trudeau Scholar and Assistant Professor of Law at the University of Ottawa, Steven Hoffman, team up in their Burden of Proof column for Vox.

This week, in "The one chart you need to understand any health study" they help readers with a simple approach to understanding how to evaluate levels of evidence. Not all research is created equally:

This is a chart from the article, modified slightly. It has been beautifully "enhanced" with the added last line by Peter Cook,  @DoodlePeter . I couldn't resist sharing Peter's version!

This is a chart from the article, modified slightly. It has been beautifully "enhanced" with the added last line by Peter Cook, @DoodlePeter. I couldn't resist sharing Peter's version!

I think the chart it is a good start, and I wish it were as simple as this. Some sneaky (or inept) researchers are good at making trials look randomized, blinded, and so on but the controls, conflicts of interest, low study numbers, etc. mean that the data they gather is not very useful at all. Sometimes, the way the papers are written, it's easy to think of the conclusion as groundbreaking and accurate, but digging deeper into the methods it becomes clear that the authors did a little.... 'creative interpretation'.

Even the highest form of evidence comes in different flavours:

Not all systematic reviews are created equally, either.

And while some evidence is stronger than other evidence, it doesn't necessarily mean anything when it comes to applying it to you, the individual. Fortunately, Ms Belluz and Mr Hoffman get it.

Even with the best available evidence from around the world at our disposal, we have to analyze it and apply it to our particular circumstances. A personal experience with the success or failure of a drug, like an allergic reaction, is more informative for you than the most rigorous study on the drug ever could be. 

It can be challenging to spot issues with quality amongst the jargon and statistics. It is so refreshing to see journalists like Julia Belluz who get this and who are raising the bar for colleagues to be responsible with their science reporting.

Follow @JuliaOfToronto and @SHoffmania on Twitter

 

Source: http://www.vox.com/2015/1/5/7482871/types-...

Projects and Initiatives toward Appropriateness in Medicine: Health Quality Ontario

When I started this website, the ambition was to collect and curate information. So much fantastic research and advocacy has already been undertaken in the area of Appropriateness in medicine, but there was no "one-stop shop" for it.

This growing movement is known by many names, like RightCare, Quaternary Prevention, Overdiagnosis, Appropriateness, Less is More in Medicine, and so on. In Canada, we seem to favour the "Appropriateness in Health Care" phrase.

The field now has so much momentum that it can be hard to keep track of everything. It's a great problem to have when you are passionate about this way of thinking, but as I'm only one person I can miss lots of great things! A friend pointed out a glaring (and wonderful, Canadian) omission:

It is the Health Quality Ontario Appropriateness Initiative, which created a systematic framework for identifying, prioritizing and assessing interventions that are potentially being used inappropriately; they offer evidence reviews and recommendations. Some topics include Measuring HbA1cs in Diabetes and Testing Vitamin B12 Levels in Neuropathy, Alopecia, Dizziness, and Fatigue.

There are many other initiatives, beyond this one and the fairly well-know Choosing Wisely campaign. See the list of PROJECTS for more.

Choosing Wisely - a catchy music video by James McCormack

"It might seem crazy . . . Less is More can often be the Best Way."
 

Dr James McCormack, co-host of the Best Science (BS) Medicine Podcast at Therapeutics Education Collaboration, created this video. It's a parody of the Pharrell Williams song "Happy," adapted to promote the concepts of evidence-based medicine, shared decision making and common sense to healthcare providers and patients.

The catchy tune highlights some suggestions from the Choosing Wisely campaign (US) and the Choosing Wisely Canada recommendations as well as ideas for using your common sense to be healthy!

Check out the video, show it to your doctor or patients, and start a healthy Less IS More conversation.


James and I will be doing a talk to the UBC Medical students this fall; I only hope we can be half as engaging. Great work, James!