A recurring theme here is the difficulty in knowing whether some (much?) of modern healthcare is actually beneficial or not. A couple of recent links that add support to that theme: 1. From JAMA, a new study
It is very important to stay on top of your health and have a check up at least once a year to ensure that you remain healthy. Many health problems are curable but you need to catch them in time. Do not wait to go see a doctor because it may be too late.
There is a lot we aren't told as far as the medical industries go.But , just watching the news and staying up on current times you will see that doctors are constantly changing there opinions on caffeine, coffee, marijuana, etc,etc
Snap out of it peopleEyes wide shut, the news and government use propaganda , so don't believe everything you hrear
Robin, I like the term "meta-scientist". Anyone in here abreast on the literature (I hope one exists) sussing out the degree to which pharma warps study results. Is it a black box? How exactly does it work? To what degree has this been quantitatively analyzed? For example, some useful numbers would be the percentage of pharma funded studies that show no or insufficient benefit of a drug, compared to the percentage of non-pharma funded studies, and the % of pharma funded studies showing drug benefit that later get disproven, as opposed to studies that don't show benefit or that aren't pharma funded.
And beyond that I'm intersted in the microsocial epistemological mechanisms that result in the production scientific studies saying what benefits the profit motive of a pharmaceutical company rather than what benefits the production of social knowledge. What's the history of this? What are the current instances? And what are effective restraints?
For people who already have coronary artery disease or something similiar, The UpToDate review is here. The first two trials are the 4S and the LIPID trial. Both I believe were funded by Pharma, but show highly significant results (by p-value) and reasonable effect sizes. These are highly significant results in the context of a highly plausible biological mechanism.
In the case of primary prevention -- i.e. preventing disease in patients who have never had a cardiac event -- this is where pharma and a govt trial ALLHAT differ. Apparently, the researchers for ALLHAT, also think they had extensive methodological problems at their own site and an accompanying editorial to the published study, linked to from their site.
@frelkins, @robin:
This is not my area, but it seems that results from 4S came out in the middle of ALLHAT, and the "placebo/usual care" group in ALLHAT wound up receiving statins (~26%). This accounted for a smaller difference in LDL between the two groups (compared to pharma Trials), as compared to prior trials. This led to a non-significant difference in cardiovascular mortality.
When evaluating a medical intervention -- its important to consider, side effects, cost, and evidence. Side effects for statins are minimal (maybe a little more than tylenol). Cost is going to be nothing, as one is coming off patent. Evidence: multiple RCTS, and very convincing biological models.
Haven't you just re-inforced Robin's point? The vast majority of the studies finding "benefit" seem to be sponsored in some way by big pharma, the people with the most to gain. Not a neutral, trustworthy source of science.
The only independent, government study seems to show no significant benefit. You question the use of even the government study - therefore it seems there's no quality, trustworthy evidence for statins either way at all! We know nothing scientific about drugs we spend many billions of dollars a year on. Why are we as a society paying for them?
Can you please, Diogenes, offer OB several high-quality peer-reviewed ungated "clean" - independent, no pharma! - studies that show significant benefit for this class of drugs or any brand-name statin? They would be useful to see.
@RobinThe govt. trial (ALLHAT), looked more at primary prevention and had a couple methodological problems (see their own website for more detail). See my earlier postings for the diff between primary and secondary prevention. Dr. Eade appears to make the same point, but it seems like you are missing it, because he's mainly ranting. Anyone who says "on these drugs that are not particularly benign. " -- has an axe to grind. Of all the meds available, this class is probably one with the least amount of side effects.
The QALY for a statin is ~ 15K-25K year for secondary prevention.
All this info is easily accessible on up-to-date, which is available at any academic medical center.
Statins are just not a good example regarding bias in medicine --- they mainly display the bias of the person doing the ranting. Just like creationists clearly have their own agenda.
Which is a better guide to the truth, the consensus of the scientific community, or a maverick collection of bloggers? . . . But at least science as an institution has mechanisms to self correct, and has a track record over hundreds of years of having come far closer to the truth during that time
I think what I've linked to in the post precisely consists of efforts of the scientific community (or portions thereof) to "self correct," that is, to point out that some treatments or practices aren't supported by good evidence.
Hal, if we reject everyone who has ever stated a prior opinion on a related subject we will have few left to rely on. What if the consensus among meta scientists, who study medical science at a meta level, is that medical scientists are way too eager to draw conclusions that favor their drug company funders? What if I am one of those meta-scientists?
Those two links make good and valid points, but one thing to keep in mind is that even though science makes mistakes, so does everyone else. The question is which is more accurate, a report in a scientific journal, or a random person's opinion? Which is a better guide to the truth, the consensus of the scientific community, or a maverick collection of bloggers? Well, of course I am wording the comparisons to hint at my opinion! But at least science as an institution has mechanisms to self correct, and has a track record over hundreds of years of having come far closer to the truth during that time.
The second link is to a diet doctor, Michael Eades, author of a book called Protein Power. He is apparently on record as being negative towards statins. What are the chances that you're going to get an unbiased opinion from him, on statins or protein consumption? Reversing his views might undercut his credibility and interfere with his livelihood.
Or maybe you will say that the right solution is to just look at the evidence and decide for yourself. But why believe that you, a layman, will come to a more accurate and informed opinion than your doctor, on things like statins? You would both be exposed to the same evidence, but he would have experience and training to put it into context, which you would not. Wouldn't this advice (to judge the evidence for yourself) be a classic example of the overconfidence bias, thinking that you probably can figure things out better than the experts, on almost every topic?
The only improvement in all-cause mortality has been in men under 65 who have been diagnosed with heart disease, and even that benefit is so small that many people question if the extra cost and side effects of the statins are worth it.Who has evidence to show this claim wrong? I've always heard that statins are one of our most clearly beneficial drugs; it is quite discouraging to see that the clearest is far from clear.
@Stuart, yea sorry, I was being curt on the general point that statins are generally extremely effective drugs. In the guidelines the JAMA article studies -- they are probably one of the most studied. The confusion on mortality data regards in the patients they are used in --- if you have documented heart disease or diabetes or other disease of your blood vessels and you have high cholesterol statins CLEARLY improve mortality (secondary prevention -- preventing someone from having another heart attack).
If you're a healthy 40 year old, with just high cholesterol, but nothing else against you -- statins seem to help and there is a lotta data supporting there use, but its not as large a benefit (this is called primary prevention -- e.g. preventing a heart attack in somoene who has never had one before). Here the guidelines on which patients should get a statin are still evolving. This should all be taken with the big grain of salt that I'm not a cardiologist.
The point regarding my curtness is that statins are probably one of the top most well studied and efficacious treatments out there. On top of that, they are cheap (off patent now) and have minimal side effects. So they aren't an ideal example to study bias in medicine as opposed to other incountable other drugs and procedures.
@retired urologist: Pharma definitely biases studies, however there is already one statin off patent, and the others will follow shortly. There is much less incentive to game the system currently on this particular class of meds -- and there effect on cholesterol is clear to anyone who has ever used them. So you have RCT data on mortality (maybe biased?, but many studies), biological mechanism, and easily quantifiable, objective effect in individual patients. I would say they are one of the most well studied and effective medical and surgical intervention.
In the absence of empirical evidence one way or the other, I'll trust a doctor's recommendations. I'm skeptical that studies can easily encompass all the variables that a doctor's recommendations might, and my health means a lot to me.
Of course if the recommendations are costly, painful or dangerous, then my decision might change.
frelkins, where has it been shown that people prefer status affiliations to health outcomes? Robin has shown that many people prefer to affiliate with high-status doctors, sure. But I don't know that he's ever shown that they'd willingly trade their health to do so. In addition, I don't know of any studies showing that patients still prefer status affiliations when they are educated on actual health outcomes of different doctors.
I really can't see anyone who is really sick or in any kind pain caring about the status of their doctor over their health.
It is very important to stay on top of your health and have a check up at least once a year to ensure that you remain healthy. Many health problems are curable but you need to catch them in time. Do not wait to go see a doctor because it may be too late.
It is truly amazing how one thing is good for you one day and it will kill you the next.
There is a lot we aren't told as far as the medical industries go.But , just watching the news and staying up on current times you will see that doctors are constantly changing there opinions on caffeine, coffee, marijuana, etc,etc
Snap out of it peopleEyes wide shut, the news and government use propaganda , so don't believe everything you hrear
Robin, I like the term "meta-scientist". Anyone in here abreast on the literature (I hope one exists) sussing out the degree to which pharma warps study results. Is it a black box? How exactly does it work? To what degree has this been quantitatively analyzed? For example, some useful numbers would be the percentage of pharma funded studies that show no or insufficient benefit of a drug, compared to the percentage of non-pharma funded studies, and the % of pharma funded studies showing drug benefit that later get disproven, as opposed to studies that don't show benefit or that aren't pharma funded.
And beyond that I'm intersted in the microsocial epistemological mechanisms that result in the production scientific studies saying what benefits the profit motive of a pharmaceutical company rather than what benefits the production of social knowledge. What's the history of this? What are the current instances? And what are effective restraints?
@robin,
For people who already have coronary artery disease or something similiar, The UpToDate review is here. The first two trials are the 4S and the LIPID trial. Both I believe were funded by Pharma, but show highly significant results (by p-value) and reasonable effect sizes. These are highly significant results in the context of a highly plausible biological mechanism.
In the case of primary prevention -- i.e. preventing disease in patients who have never had a cardiac event -- this is where pharma and a govt trial ALLHAT differ. Apparently, the researchers for ALLHAT, also think they had extensive methodological problems at their own site and an accompanying editorial to the published study, linked to from their site.
@frelkins, @robin:
This is not my area, but it seems that results from 4S came out in the middle of ALLHAT, and the "placebo/usual care" group in ALLHAT wound up receiving statins (~26%). This accounted for a smaller difference in LDL between the two groups (compared to pharma Trials), as compared to prior trials. This led to a non-significant difference in cardiovascular mortality.
When evaluating a medical intervention -- its important to consider, side effects, cost, and evidence. Side effects for statins are minimal (maybe a little more than tylenol). Cost is going to be nothing, as one is coming off patent. Evidence: multiple RCTS, and very convincing biological models.
Diogenes, every study has "methodological problems." Give a link; your blog has only four posts, none of which mention statins or primary preventions.
@Diogenes
Haven't you just re-inforced Robin's point? The vast majority of the studies finding "benefit" seem to be sponsored in some way by big pharma, the people with the most to gain. Not a neutral, trustworthy source of science.
The only independent, government study seems to show no significant benefit. You question the use of even the government study - therefore it seems there's no quality, trustworthy evidence for statins either way at all! We know nothing scientific about drugs we spend many billions of dollars a year on. Why are we as a society paying for them?
Can you please, Diogenes, offer OB several high-quality peer-reviewed ungated "clean" - independent, no pharma! - studies that show significant benefit for this class of drugs or any brand-name statin? They would be useful to see.
@RobinThe govt. trial (ALLHAT), looked more at primary prevention and had a couple methodological problems (see their own website for more detail). See my earlier postings for the diff between primary and secondary prevention. Dr. Eade appears to make the same point, but it seems like you are missing it, because he's mainly ranting. Anyone who says "on these drugs that are not particularly benign. " -- has an axe to grind. Of all the meds available, this class is probably one with the least amount of side effects.
The QALY for a statin is ~ 15K-25K year for secondary prevention.
All this info is easily accessible on up-to-date, which is available at any academic medical center.
Statins are just not a good example regarding bias in medicine --- they mainly display the bias of the person doing the ranting. Just like creationists clearly have their own agenda.
Which is a better guide to the truth, the consensus of the scientific community, or a maverick collection of bloggers? . . . But at least science as an institution has mechanisms to self correct, and has a track record over hundreds of years of having come far closer to the truth during that time
I think what I've linked to in the post precisely consists of efforts of the scientific community (or portions thereof) to "self correct," that is, to point out that some treatments or practices aren't supported by good evidence.
Hal, if we reject everyone who has ever stated a prior opinion on a related subject we will have few left to rely on. What if the consensus among meta scientists, who study medical science at a meta level, is that medical scientists are way too eager to draw conclusions that favor their drug company funders? What if I am one of those meta-scientists?
Those two links make good and valid points, but one thing to keep in mind is that even though science makes mistakes, so does everyone else. The question is which is more accurate, a report in a scientific journal, or a random person's opinion? Which is a better guide to the truth, the consensus of the scientific community, or a maverick collection of bloggers? Well, of course I am wording the comparisons to hint at my opinion! But at least science as an institution has mechanisms to self correct, and has a track record over hundreds of years of having come far closer to the truth during that time.
The second link is to a diet doctor, Michael Eades, author of a book called Protein Power. He is apparently on record as being negative towards statins. What are the chances that you're going to get an unbiased opinion from him, on statins or protein consumption? Reversing his views might undercut his credibility and interfere with his livelihood.
Or maybe you will say that the right solution is to just look at the evidence and decide for yourself. But why believe that you, a layman, will come to a more accurate and informed opinion than your doctor, on things like statins? You would both be exposed to the same evidence, but he would have experience and training to put it into context, which you would not. Wouldn't this advice (to judge the evidence for yourself) be a classic example of the overconfidence bias, thinking that you probably can figure things out better than the experts, on almost every topic?
OK, I've read Dr. Eades's post and two others he links, and I'm convinced; he's right on the money. Key quote:
In contrast, the only large clinical trial funded by the government, rather than companies, found no statistically significant benefit at all…”
The key claim is:
The only improvement in all-cause mortality has been in men under 65 who have been diagnosed with heart disease, and even that benefit is so small that many people question if the extra cost and side effects of the statins are worth it.Who has evidence to show this claim wrong? I've always heard that statins are one of our most clearly beneficial drugs; it is quite discouraging to see that the clearest is far from clear.
@Stuart, yea sorry, I was being curt on the general point that statins are generally extremely effective drugs. In the guidelines the JAMA article studies -- they are probably one of the most studied. The confusion on mortality data regards in the patients they are used in --- if you have documented heart disease or diabetes or other disease of your blood vessels and you have high cholesterol statins CLEARLY improve mortality (secondary prevention -- preventing someone from having another heart attack).
If you're a healthy 40 year old, with just high cholesterol, but nothing else against you -- statins seem to help and there is a lotta data supporting there use, but its not as large a benefit (this is called primary prevention -- e.g. preventing a heart attack in somoene who has never had one before). Here the guidelines on which patients should get a statin are still evolving. This should all be taken with the big grain of salt that I'm not a cardiologist.
The point regarding my curtness is that statins are probably one of the top most well studied and efficacious treatments out there. On top of that, they are cheap (off patent now) and have minimal side effects. So they aren't an ideal example to study bias in medicine as opposed to other incountable other drugs and procedures.
@retired urologist: Pharma definitely biases studies, however there is already one statin off patent, and the others will follow shortly. There is much less incentive to game the system currently on this particular class of meds -- and there effect on cholesterol is clear to anyone who has ever used them. So you have RCT data on mortality (maybe biased?, but many studies), biological mechanism, and easily quantifiable, objective effect in individual patients. I would say they are one of the most well studied and effective medical and surgical intervention.
For those who missed it (especially @ diogenes), David J. Balan's post (and the distinguished review it cites) sums up the situation here.
In the absence of empirical evidence one way or the other, I'll trust a doctor's recommendations. I'm skeptical that studies can easily encompass all the variables that a doctor's recommendations might, and my health means a lot to me.
Of course if the recommendations are costly, painful or dangerous, then my decision might change.
frelkins, where has it been shown that people prefer status affiliations to health outcomes? Robin has shown that many people prefer to affiliate with high-status doctors, sure. But I don't know that he's ever shown that they'd willingly trade their health to do so. In addition, I don't know of any studies showing that patients still prefer status affiliations when they are educated on actual health outcomes of different doctors.
I really can't see anyone who is really sick or in any kind pain caring about the status of their doctor over their health.