Evaluating Medical Evidence for Journalists

Ivan Oransky, MDExecutive Editor, Reuters Health

Association of Health Care JournalistsAtlanta

April 19, 2012

Can You Trust Journal Studies?• How good is peer review?• Positive publication bias:

Publish a trial that will bring US$100,000 of profit or meet the end-of-year budget by firing an editor. -- Former BMJ editor Richard Smith

• Over-reliance on embargoed studies

• How often it turns out to be wrong

Embargoes and the Ingelfinger Rule

By the late 20th century, journals needed to compete not just with each other but with newspapers and other media…In 1969, the Journal articulated this relationship in its Ingelfinger Rule, a policy against publishing anything that had already appeared elsewhere. Other journals followed suit. This rule, combined with embargo policies, has led to a carefully choreographed production in which medical journals and the popular press work cooperatively and competitively to influence the news cycle.

-- NEJM, April 19, 2012

Even Without Embargoes, We’d Still Have Ingelfinger

How Often Are Studies Wrong?

Ioannidis JPA. PLoS Med 2005; 2(8): e124

How Often Are Studies Wrong?

Retractions on the Rise

-The Wall Street Journal

Retractions on the Rise

-Neil Saunders

The Unofficial Record Holder

This is Transparency?

Conference Pitfalls

Conference Pitfalls• Conferences select presenters based on < 1000 words

• Urologists at U of Florida & Indiana U studied 126 randomized controlled trials presented in 2002-2003

Conference Pitfalls• RCTs are the “gold standard” of medical evidence

• But the quality of that evidence wasn’t pretty • No abstract said how trial subjects were randomly

assigned to different treatments or placebos• None told how the study ensured that neither the

researchers nor their doctors knew which they got• Only about a quarter said how long researchers

followed the subjects in the trial

Just Say No

Sometimes, it’s better not to cover something. But if you must…

Always Read the StudyWriting about a study after reading just a press

release or an abstract – without reading the entire paper –

is journalistic malpractice

How to Get Studies• www.EurekAlert.org for embargoed material • Association of Health Care Journalists membership

includes access to Cochrane Library, Health Affairs, JAMA, and many other journals www.healthjournalism.org

• ScienceDirect (Elsevier) gives reporters free access to hundreds of journals www.sciencedirect.com

• Open access journals (e.g., Public Library of Science www.plos.org)

• Ask press officers, or the authors

How Good Was The Study?• Was it:– Peer-reviewed?– Published? Where?

• Was it in humans?– It’s remarkable there are any mice left with

cancer, depression, or restless leg syndrome

• Size matters

• Was it well-designed?

From Covering Medical Research, Schwitzer/AHCJ

What’s Your Angle?• Are you trying to help readers, listeners, and

viewers make better health care decisions?

• Covering a study because it has a good business angle, or it’s about a local project, is perfectly OK, but it doesn’t mean readers deserve less evidence and skepticism

Who Could Benefit?• How many people have the disease?

• Keep potential disease-mongering in mind

How Effective is the Treatment?• Clinically significant endpoints, or surrogates –

does this matter?

• Preventing complications? How many?

• Always remember to quantify results, not just “patients improved”

What Are The Side Effects?• Every treatment has them

• Where to look:– Go beyond press releases and abstracts– Look at tables, charts, and results sections

Who Dropped Out?• Why did they leave the trial?

• Intention to treat analysis

How Much Does it Cost?• If it’s ready to be the subject of a story, someone

has projected the likely cost and market. – At least ask.

Who Has an Interest?• Disclose conflicts

• PharmedOut.org

• Dollars For Docs series http://projects.propublica.org/docdollars/

Are There Alternatives?• Did the study compare the new treatment to

existing alternatives, or to placebo?

• What are the advantages and disadvantages (and costs) of those existing alternatives?

Don’t Rely Only on Study Authors• Find outside sources. Here’s how:

Use Anecdotes Carefully• Is the story representative?

• Does the source of the story have any conflicts?

Watch Your Language• Lifestyle/diet – are they randomized controlled

trials, or just observational?

• If observational, make the language fit the evidence:

– YES: “tied,” “linked”

– NO: “reduces,” “causes”

Absolute vs. Relative Risk• Consider the risk for blindness in a patient with

diabetes over a five-year period

• The risk for blindness is 2 in 100 (2%) in people who get the conventional treatment and 1 in 100 (1%) with a new drug

• The absolute difference is derived by subtracting the lower risk from the higher risk: 2% - 1% = 1%.

From Covering Medical Research, Schwitzer/AHCJ

Absolute vs. Relative Risk• Expressed as an absolute difference, the new drug

reduces the five-year risk for blindness by 1%.

• The relative difference is the ratio of the two risks.

• Given the data above, the relative difference is:

1% ÷ 2% = 50%

• Expressed as a relative difference, the new drug cuts the risk of blindness in half.

From Covering Medical Research, Schwitzer/AHCJ

Number Needed To Treat• Same concept as number needed to screen

• Can be calculated from absolute risk: – 100/absolute risk difference (as a percentage)

A Dirty Little Secret

Keep a biostatistician in your back pocket

Photo by Peyri Herrera, on Flickr

Keep Yourself Honest

• Use HealthNewsReview.org

Acknowledgement/Contact• Nancy Lapid, Reuters Health

ivan-oransky@erols.comTwitter: @ivanoransky