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...

Use your B.R.A.I.N. A Decision Support Tool

The Centre for Collaboration, Motivation, and Innovation (CCMI) is a non-profit organization dedicated to building skills and confidence for better health and health care. Their vision is "to improve health outcomes through helping people take active roles in their health."

The BRAIN Informed Decision Making Aid

Achieving this vision entails the development of tools that can facilitate patient-provider conversations. To that end, they have adapted the BRAIN Informed Decision Making tool from the International Childbirth Association.

At the recent BC Patient Safety Quality Council's Quality Forum (#QF16), I was asked to give a talk on Choosing Wisely and was put into the "Patient Empowerment" breakout session. It was fortuitous that my talk preceded that of the CCMI team as I got to see their presentation on the tool and learn about its development (slides accessible here).

Helping a patient to explore the [B]enefits, [R]isks, [A]lternatives, their [I]ntuition, and [N]ext steps, the BRAIN tool can assist people navigating any significant health choice.

You can view and download the PDF on the CCMI's website. The simple format and generalizability means it could easily become a 'go to' tool for patients and clinicians who wish to engage in shared decision-making.

Please feel free to leave your feedback on this tool in the comments section below; the input can be forwarded to the CCMI team. Has it been a helpful tool for you as a patient or caregiver? Do your patients find the format straightforward?
 

More

Seeking more tools like this to facilitate patient-provider discussions around important health choices? Less is More includes a list of mainly Shared Decision Making Tools, in the hands-on resource section.

Source: http://www.centrecmi.ca/wp-content/uploads...

Can this app prevent Overtesting? A look at SnapDx

Sometimes, a new idea is exactly what we need to tackle a longstanding, otherwise insurmountable problem. A little bit of innovation can go a long way.

On the other hand, some new technologies are sexy and flashy but they don't really make a difference for society, or they generate new problems worse than the old.

I'm always on the lookout for creative solutions to the problem of overdiagnosis. Patients, healthcare providers, and society as a whole need to make changes to help create a sustainable, high-quality health care system.

In Doctors create app to help diagnose, treat patients at point of care, Globe and Mail journalist Ivor Tossel describes the aims behind SnapDx.

Dr. Rahul Mehta, an internal medicine resident at the University of Calgary, partnered with colleague Dr. Aravind Ganesh to create the SnapDx app. The app uses evidence-based guidelines to help guide physicians delivering care.

SnapDx Clinical is an efficient bedside assessment tool designed for use by medical trainees and clinicians at the point of care.

We provide the best evidence-based questions and tests to be used as part of your history and physical examination to confidently sort through your differential diagnosis. (from iTunes App description)

The idea is that SnapDx can help aid decisions about diagnosis, giving clinical probabilities that might override the need for ordering laboratory or radiological tests. It does this by emphasizing thorough physical exams, filtering these findings through well-evidenced decision-making tools, and providing probabilities for diagnosis.

Try downloading the SnapDx App (iTunes) yourself, or see the screenshots below for an idea of what it looks like.

I applaud the effort, and I imagine it must have taken a heroic effort to tackle the statistical nightmare behind the scenes, converting everything into a standardized interface.

Despite recognizing this, I must admit I found it a bit cumbersome and hard to understand. Each section has an estimated pre-test probability which is often set to the prevalence rate from a major research study; then, you tick yes/no to various scoring criteria (which are helpfully described in the Info sections). With this, you see the probability for/against a diagnosis. I think. Though it doesn't explicitly say if you should order a test, or which test you should order.

I got a bit bogged down in the details. One big issue I had is that I was not clear on is how to set the positive pre-test probability accurately.

 

For example: when I tried the Pulmonary Embolus (PE) tool, I was thinking of a patient who had recent surgery, recent cancer, immobilization, chest pain, tachypnea, no fever, a normal blood gas, and a normal chest x-ray. There was almost no other diagnosis possible besides a clot in his lungs. Yet because he did not have signs of DVT, hemoptysis, a clotting history, or tachycardia he would not score very high on any of the scales. Of course my pre-test probability for him was high, but I don't know if it was 50% or 99%, and the possible harms of a CT-scan were outweighed by the benefit of ensuring the treatment (high-dose blood thinner; possibly quite harmful) was in fact necessary.

The ambition of Drs Mehta and Ganesh is admirable, and I will keep the app around, looking for future iterations of it. It has the potential to improve clinical accuracy and to decrease ordering of tests that would only confirm what we already know from physical exam. 

Using our detective skills rather than requisitioning a test? It is a great idea.