The nnt scale may be useful, but it does not address whether an individualor groups of individuals can benefit from a free physical exam and screenings. The real problem is the U.S. care delivery system favors paying for treatment of chronic diseases rather than preventing them in the first place. There are few longitudinal studies that would actually determine whether basic preventative health care is cost effective (e.g. someone finds out they do have a treatable blood pressure problem) rather than the issue going undiagnosed.
I don't agree the NTT is infinite regarding stents in non-heart attack patients. There are HUGE SHADES OF GRAY. Patients who have symptoms that are attributable to narrowed /diseased coronaries (heart arteries) can be sub classified according to risk- with stenting quite reasonable for high risk patients and/or patients who fail medical Rx. However, I definitely agree that the industry pushes Rx modalities not based on on their true usefulness ( NTT) . GOOD article !
2
When 2000 people take aspirin believing they are helping reduce heart attack, which happens for one lucky one but 4 times as many are not, it's a good question to ask: Does our reliance on pills hijack other healthy behaviors which may have a lot better chance of saving us from hear attack, then the very idea of drugs, tests, and therapies is highly questionable as we forget the psychological shift that we are prone to make which makes us further removed from a healthy lifestyle with a far better promise of positive results than such dependencies.
Aspirin will reduce the rate of heart attacks from 3.6 to 2.6. That is a huge difference. Looking at it another way, 1 in 2000 will avoid having a heart attack. I wish I could buy a lottery ticket that will give me comparable odds for a similar outcome for the price of an aspirin!
What is the NNT for appendectomy ?
Just as there is NNT - number needed to treat there is also a NNH - numbers needed to harm. With both in hand you can reasonably explain what is to be expected, based on a well designed study with good confidence intervals. But one must understand that we can predict which of the study subjects will actually benefit most of the times.
1
There are 2 other snags with aspirin to prevent heart attacks.
1. The heart attacks prevented are typical non-fatal.
2. The aspirin increases the risk of severe GI tract bleeding events, indeed on average there are 2 of these for every non-fatal heart attack prevented.
Looks like the benefits of this aspirin taking are largely limited to the shareholders of Bayer.
1. The heart attacks prevented are typical non-fatal.
2. The aspirin increases the risk of severe GI tract bleeding events, indeed on average there are 2 of these for every non-fatal heart attack prevented.
Looks like the benefits of this aspirin taking are largely limited to the shareholders of Bayer.
5
Unpopular here, but NNT has at least 2 serious problems as a primary means of communicating risk. First, NNT isn't measured, it's calculated by multiplying probabilities from various studies. Neither probability of disease nor of benefit is known with certainty; they vary from person to person in ways that are neither fully understood nor precisely measurable. Multiplication of uncertainties gives more uncertainty; the idea that an NNT of 30 is better than one of 31, or even 300, is highly questionable. NNTs should include confidence limits multiplying upper and lower limits of all the studies from which they are derived. Emphatic about the uncertainty of benefits from intervention, the referenced website fails to convey this uncertainty of derived NNTs in any useful way. Second, Zeno's the guy who said to walk a league, you had to walk half a league, and half of that, and so on. Since intervening fractions are infinite, it's impossible. As it is in fact possible to walk a league, this logic is perniciously wrong, but NNT invites it by analyzing interventions singly instead of cumulatively. How long and how many interventions are enough? The NNT for not smoking that next cigarette is probably in the billions, if calculable at all, so you might as well smoke it anyway, heart attacks and lung disease be damned. NNT is by nature a nihilist approach to all interventions, including preventive ones. But the cumulative public health impact of not doing these interventions is huge.
5
This is information everyone should learn and remember, especially when dealing with cardiologists. I refer to the cult of cardiology, with members chanting from a liturgy written by the pharmaceutical industry. Evidently cardiologists can be disciplined by their official organization if they don't prescribe a statin, a blood thinner and a beta blocker to a patient who presents with any symptoms of cardiac dysfunction. The Cochrane Collaboration gives realistic stats on statins, indicating that if you give 1,000 people a statin over a five year period, you will avoid 18 incidents of CVD (cardiovascular disease). For many, the side effects of statins seriously impact their lives.
Doctors don't want to hear stats on side effects of all medications for "heart disease" from a patient, nor do they have time to read all the studies that evaluate the cost/benefit ration themselves. Instead, they recite the easily digested promotional material that they receive from the pharmaceutical industry.
People need to educate themselves, and decline medications, in spite of the fear mongering practiced by many physicians.
Doctors don't want to hear stats on side effects of all medications for "heart disease" from a patient, nor do they have time to read all the studies that evaluate the cost/benefit ration themselves. Instead, they recite the easily digested promotional material that they receive from the pharmaceutical industry.
People need to educate themselves, and decline medications, in spite of the fear mongering practiced by many physicians.
7
I don't understand the sinus infection example. The graphic appears to be saying that out of the 15 people who take antibiotics, 1 person gets better, 2 do not, but what about the other 12? Either they get better or they don't, they aren't stuck in some sort of sick-and-not-sick limbo.
It seems like the wording in the graphic is misleading, so I'm assuming the 12 are those who see no change in outcome from taking antibiotics and that of the 3 who don't get better, 1 would have if they all had taken antibiotics (all on average, of course).
It seems like the wording in the graphic is misleading, so I'm assuming the 12 are those who see no change in outcome from taking antibiotics and that of the 3 who don't get better, 1 would have if they all had taken antibiotics (all on average, of course).
1
The labeling could have been better. Would have been better to say "...resolved by antibiotics".
Of the 15 people with acute sinusitis, 12 would have recovered even if they hadn't taken antibiotics, only one recovers BECAUSE of the antibiotics, and two don't recover DESPITE antibiotics.
In other words, taking antibiotics raises your chance of recovery from 80% to 87%, or, looked at the other way, reduces your chance of staying sick from 20% to 13%.
Just look at all the ways these numbers can be presented: failure reduced by 33% (7/20), failure reduced by 7% (20-13), NNT 15 (1/7), recovery increased by 7% (87-80) or recovery increased by 9% (7/80). Every one of these statistics is useful in its own way. Of course pharma, and people who are suffering terribly, and the doctors treating them, will focus on the first, while people looking at large populations will tend to focus on the others.
Of the 15 people with acute sinusitis, 12 would have recovered even if they hadn't taken antibiotics, only one recovers BECAUSE of the antibiotics, and two don't recover DESPITE antibiotics.
In other words, taking antibiotics raises your chance of recovery from 80% to 87%, or, looked at the other way, reduces your chance of staying sick from 20% to 13%.
Just look at all the ways these numbers can be presented: failure reduced by 33% (7/20), failure reduced by 7% (20-13), NNT 15 (1/7), recovery increased by 7% (87-80) or recovery increased by 9% (7/80). Every one of these statistics is useful in its own way. Of course pharma, and people who are suffering terribly, and the doctors treating them, will focus on the first, while people looking at large populations will tend to focus on the others.
4
I'm sorry, but using statistics like these seems like such a ham-fisted way to offer treatment to people.
Healing takes place on an individual basis. Some people respond to antibiotics for sinusitis, others have a chronic condition that may be exacerbated by antibiotics and cured by something as simple as copious amounts of saline nose spray.
While diseases/conditions can be put into a statistical hopper and treatments/cures can pop out at the other end, an individual human (and for that matter, any living creature) requires individual, customized care for optimum health.
Inevitably, that kind of proposition suggests participation/responsibility by the individual to make lifestyle changes for better health -- but that's a whole other story.
Healing takes place on an individual basis. Some people respond to antibiotics for sinusitis, others have a chronic condition that may be exacerbated by antibiotics and cured by something as simple as copious amounts of saline nose spray.
While diseases/conditions can be put into a statistical hopper and treatments/cures can pop out at the other end, an individual human (and for that matter, any living creature) requires individual, customized care for optimum health.
Inevitably, that kind of proposition suggests participation/responsibility by the individual to make lifestyle changes for better health -- but that's a whole other story.
5
If someone offers you a preventative treatment, your only way of evaluating its efficacy is by looking at how it has helped others. The statistics are key.
Considering how fragmented and expensive our health care system is NNT doesn't consider the fact that many of us can't afford treatment for anything. Before we go and say that people should or should not do something or take something perhaps we should make sure that they have access to decent health care.
2
Isn't that what Obama is trying to do? Don't the Republicans oppose him no matter what he does?
5
One aspirin a day costs pennies. There is very little financial cost to changing one's diet either (if you make reasonable choices).
No one has written about this yet, so I will. The article uses NNT appropriately for antibiotic treatment for sinusitis, but not for aspirin, or diet, or stents. NNT means one thing for treatment, and another thing for prevention. An antibiotic treatment for sinusitis cures the sinusitis or it doesn't. And you can measure that and supply a NNT. But prevention of disease, like a heart attack, is not a treatment (in the sense that NNT requires). Aspirin, diet, and stents may cure you of a heart attack , but these trials do not tell you whether they do or don't. (They probably don't.) If significant, they tell you if the disease has been delayed - and that's all. Many times, the delay is just between 1 to 12 months, because these trials stop when significance occurs. In these 3 cases, NNT should really be "Number needed to delay by one year", or NND/year. Most pharmaceuticals will not compute that number - probably because you would not buy that "treatment" if you knew it. So does aspirin cure heart attacks? Of course not. Does it delay it? It can. How long? Who knows.
8
Once again the deaths cited should be labeled "early deaths". Also, once again, concentrating on deaths may not be pragmatic. What's even more important is prolonged quality of life, in conjunction with other measures of course.
3
This is an overly simplistic and somewhat misleading interpretation of NNT. If one heart attack is prevented for every 2000 people treated, it does not mean that only 1 person should have been treated because none of the others had any benefit. Precision medicine is not that precise - ie, it's not true that only 1 person responds to aspirin and we just have to figure out who that 1 person is. More likely, most (but not all) of the 2000 people treated had some tiny individual reduction in risk which, when aggregated, meant that 1 heart attack was prevented.
Thus, the statement that "seven of eight people suffering an asthma attack see no benefit at all from steroids with respect to preventing hospitalization" is misleading, even if it is technically correct. All 8 patients likely benefited from steroids, but in only 1 patient was that benefit sufficient to prevent hospitalization.
I don't think I'm explaining that very well, but anyway this is yet another example of how a lot of explanations can hide in statistics.
Thus, the statement that "seven of eight people suffering an asthma attack see no benefit at all from steroids with respect to preventing hospitalization" is misleading, even if it is technically correct. All 8 patients likely benefited from steroids, but in only 1 patient was that benefit sufficient to prevent hospitalization.
I don't think I'm explaining that very well, but anyway this is yet another example of how a lot of explanations can hide in statistics.
6
It seems that the NNT assumes one treatment for a person with one illness. What about the millions of people taking multiple prescriptions? Is it not possible that some of these treatments are influencing the results of other drugs? We can study how two drugs interact in the body, but some seniors take ten or more medicines. How accurate is an NNT in that scenario?
3
I had 4 different primary care physicians before I was asked if I had a shingles innoculation and I am 73 YO. Shingles if you don't know can be extremely painful and can rresult in blindness or death but the numbers are low - so I am told.
I contracted shingles after having a massive infection and a huge dose of antibiotics - ciprofloxin - first ever and if you don't know large doses of antibiotics really reduce your resistance to some issues including shingles. I have virtually continuous light pain around my eye although after 5 years it is gradually reducint.
I take a enteric coated child's aspirin daily along with a multi vitamin. The cost of this is maybe 3 cents a day and with no down side risk - why not.
With regard to stents, the NYt several years ago had a story about a physician in TX that was slapping stents into everyone who came into his office and because he was very sloppy, several people died because of the procedure. He got a 10 year prison sentence and had a very large fine also.
If you have a complex case, get to a large university teaching hospital because the small 200 bed hospitals can't address complex cases and could do lasting harm to you or your loved ones which I saw happen to a family member.
I contracted shingles after having a massive infection and a huge dose of antibiotics - ciprofloxin - first ever and if you don't know large doses of antibiotics really reduce your resistance to some issues including shingles. I have virtually continuous light pain around my eye although after 5 years it is gradually reducint.
I take a enteric coated child's aspirin daily along with a multi vitamin. The cost of this is maybe 3 cents a day and with no down side risk - why not.
With regard to stents, the NYt several years ago had a story about a physician in TX that was slapping stents into everyone who came into his office and because he was very sloppy, several people died because of the procedure. He got a 10 year prison sentence and had a very large fine also.
If you have a complex case, get to a large university teaching hospital because the small 200 bed hospitals can't address complex cases and could do lasting harm to you or your loved ones which I saw happen to a family member.
7
Since shingles is the result of latent eruption of the zoraster virus, present in all of us who had chickenpox earlier in life, I don't see how antibiotics can figure in. My wife has had post herpetic neuralgia for two years after contracting shingles and hasn't used antibiotics for many years due to allergies (hives). She can't have the shingle shot due to egg allergies. I got the shot and so far, knock on wood, no shingles.
I agree with you REB, but I'm going to expand on your comment.
Doctors believe that the re-emergence of the virus is due to weakening of the immune system, which happens as you age. In Butch's case, it sounds as if his immune system had been weakened significantly (ie, he had a self-described "massive infection" right before he got shingles) so that seems to be the most likely cause from the evidence presented. I also can't find anything on the internet about a link between shingles and antibiotic use except that antibiotics are used to treat bacterial infections of the blisters resulting from shingles.
Doctors believe that the re-emergence of the virus is due to weakening of the immune system, which happens as you age. In Butch's case, it sounds as if his immune system had been weakened significantly (ie, he had a self-described "massive infection" right before he got shingles) so that seems to be the most likely cause from the evidence presented. I also can't find anything on the internet about a link between shingles and antibiotic use except that antibiotics are used to treat bacterial infections of the blisters resulting from shingles.
2
The correction alone at the bottom would make this article theoretically void as it disproves most of what it says. Also, the portion about the antibiotic(s) and sinusitis seems off to me. Antibiotics are a huge class of medications, all with different efficacies and effectiveness to tackle the illness. To generalize them all into one sentence seems miscalculated, and/or questionable.
2
i have had sinus infections all my life. In the 50s antibiotics were the only treatment. Beginning in the 60s antihistamines were added. Now I take Zyrtec, Singulair and Flonase to prevent sinus infections but if I get one I tend to develop bronchitis or pneumonia; therefore, my doctor does prescribe antibiotics for my sinusitis. I must be that one person who recovers with antibiotic treatment of sinus infections because I have never had a sinus infection that wasn't cured by antibiotics.
3
The moving dots illustrate brilliantly an abstract concept difficult to understand by the lay population.
3
I love www.thennt.com. It is a shame this article did not compare the NNT arrived at for statins versus Mediterranean diet... if a NNT of 30 is considered weak sauce for Med diet, then people will be shocked at how weak the NNT is for statins (1 in 83). In fact, if statins were marketed this way instead of using statistical tricks like relative risk reduction, I wonder if statin therapy would be as strongly pushed for as it is (not to mention the NNT for statins as primary prevention is infinity).
9
Good question, but one should "never" compare NNT for two treatments tested in different studies. The reason is that the NNT (one divided by the absolute risk reduction if you remember stats 101) is determined not just by the effectiveness of the drug (relative risk reduction) but also by the prevalence in the groups studied, and by the duration of therapy. So unless those are very similar, the comparison will be inevitably misleading.
To illustrate, imagine two chronic treatments (say statin and diet) which are equally effective, reducing the chance of getting sick by 25%. But one is tested in a high risk population for a long time, and the other in a low risk population for a short time. The second will have a higher NNT.
Assuming that the benefit of a drug remains constant over time (a huge assumption), the NNT will drop as time passes. So here's an odd paradox: a drug which appears useless because of a large NNT will appear more useful if used longer!
In my book, the best approach when counselling an individual patient about whether or not to take a drug, is to assume the relative risk reduction is the same across all populations unless there is reason to believe otherwise (a huge assumption I admit), then calculate his personal risk (using something along the lines of the Framingham risk calculator), and multiply those two together to get "his" absolute risk reduction The inverse of that equals the Number-of-identical-twins Needed to Treat".
To illustrate, imagine two chronic treatments (say statin and diet) which are equally effective, reducing the chance of getting sick by 25%. But one is tested in a high risk population for a long time, and the other in a low risk population for a short time. The second will have a higher NNT.
Assuming that the benefit of a drug remains constant over time (a huge assumption), the NNT will drop as time passes. So here's an odd paradox: a drug which appears useless because of a large NNT will appear more useful if used longer!
In my book, the best approach when counselling an individual patient about whether or not to take a drug, is to assume the relative risk reduction is the same across all populations unless there is reason to believe otherwise (a huge assumption I admit), then calculate his personal risk (using something along the lines of the Framingham risk calculator), and multiply those two together to get "his" absolute risk reduction The inverse of that equals the Number-of-identical-twins Needed to Treat".
2
So how many lives are saved by aspirin every year in the US? 1 in 2000/2 years sounds small, but there are a lot of people at risk.
There are 1.5 million heart attacks/year in the US and about 1/3 of them are fatal according to the internet. How many deaths are prevented each year by aspirin?
The calculation isn't simple but its an important part of this story. If there were NO hazards to taking aspiring, its obviously worth doing.
This is an important article but we need more facts. Otherwise, this ends up misleading people. As for personalized medicine solving the problem - good luck. Most of us won't live long enough to see that day I'm afraid.
There are 1.5 million heart attacks/year in the US and about 1/3 of them are fatal according to the internet. How many deaths are prevented each year by aspirin?
The calculation isn't simple but its an important part of this story. If there were NO hazards to taking aspiring, its obviously worth doing.
This is an important article but we need more facts. Otherwise, this ends up misleading people. As for personalized medicine solving the problem - good luck. Most of us won't live long enough to see that day I'm afraid.
2
In Businessweek article dated Jan. 28, 2008, John Carey provided an analysis of the value of statins using NNTs. His conclusion was that statins have virtually no beneficial effect on people without heart disease. Yet, millions of people are encouraged to consume them. In the case of statins, the pharma industry's financial support of the American heart Association that, in turn, encourages prescribing statins is an obvious conflict of interest. Many are no longer brand name and so costs to patients have dropped. Still, they are "dream" customers for the pharma industry - consuming the drug for the rest of their lives with no hope for a cure.
7
Excellent article. Most people just don't 'get this' at all. I have several chronic conditions, most related to my Primary Immune Deficiency. As a result I take many medications and have IVIG monthly. When I talk with others (on line) about treatments and medications, most think 1) whatever happens to THEM with a medication is what will happen with everyone, or 2) the worst horror story from someone they know is what will happen to them, or 3) some combination of 1 and 2. There is simply NO WAY for people to grasp the size of population studies that are needed to establish what happens to enough people to make a conclusion of sorts. Life is trial and error....get used to it.
11
Excellent article, however, there should have been some discussion on cancer and chemotherapy. The cost of chemotherapy is very high, especially for the new therapies. In many cases, the small extension of life is hardly justified, especially if you consider the side effects and diminished quality of life.
Another point is how drug companies and/or researchers can distort their conclusions using statistics. For example, if people follow the Mediterranean diet there would be 1.4 deaths versus 2.4 deaths - a 40% reduction! Sounds a lot better than a 30 N.N.T. metric.
Another point is how drug companies and/or researchers can distort their conclusions using statistics. For example, if people follow the Mediterranean diet there would be 1.4 deaths versus 2.4 deaths - a 40% reduction! Sounds a lot better than a 30 N.N.T. metric.
10
I think I would let people make up their own minds whether chemo is worth it or not. I have a friend who was diagnosed with stage four breast cancer 8 years ago. She had chemo and radiation and is still alive and leading a normal life today. Her son just got married this summer. If she hadn't been trested, she would never have seen that happen. I have other friends who have been diagnosed with cancer. I think most of them would tell you chemo was worth it.
2
I object to the a bias in this article that results from measuring the benefits of treatment or lifestyle changes only in terms of extreme medical events. For many of these treatments and lifestyle changes, there are other benefits, both medically and in quality of life. For example, changing to a Mediterranean diet and increasing exercise may do more than prevent heart attacks. One medical benefit, for full or borderline type 2 diabetics, could be better blood sugar management. A non-medical benefit could be increased capacity to perform a variety of physical tasks, at work or leisure. Any treatment must be considered in terms of the patient's total health, so public policy (and Medicare and insurance coverage) should not be focused on NNT to the point that useful treatments are excluded, even if they are not golden bullets.
26
"There is a complementary metric known as the number needed to harm, or N.N.H., which says that if that number of people are treated, one additional person will have a specific negative outcome."
but "negative outcome" could range from indigestion to death. and sometimes we can not even imagine all of the possible negative (and positive) outcomes.
"So, if aspirin is cheap and doesn’t cause much harm, it might be worth taking, even if the chances of benefit are small. But this already reflects a trade-off we rarely consider rationally."
speak for yourself. this is precisely why i take a multi-vitamin, even though i am probably wasting my time and money, given a fairly healthy diet.
but "negative outcome" could range from indigestion to death. and sometimes we can not even imagine all of the possible negative (and positive) outcomes.
"So, if aspirin is cheap and doesn’t cause much harm, it might be worth taking, even if the chances of benefit are small. But this already reflects a trade-off we rarely consider rationally."
speak for yourself. this is precisely why i take a multi-vitamin, even though i am probably wasting my time and money, given a fairly healthy diet.
3
Excellent info. Evidence based medicine so important but also so disconcerting for the trustful. The dots are distracting but make the point.
3
Aspirin might have other health benefits besides the heart.
7
The animated graphics that accompany this article sure are distracting. I wish there were a way to stop their endless looping.
8
Great article! Thanks for making some of this clear!
1
This article leaves out the most important conclusion.... We know little about our bodies and medical research isn't asking the right questions. We treat our differences as random variation when a lot is not random but just unknown.
Suppose we learned a bit more about the mechanism by which aspirin affects heart attacks. Suppose then we only prescribed it to that group. Same drug, but now much more effective. Unfortunately, since aspirin is already proven effective, generic, and dirt cheap, and because we continue to cut funding for basic research, there is no incentive for anyone to learn more about it.
This example holds for cancer drugs, too. We know 5FU works, so we no longer researching the how, the why, or the best delivery mechanism.
As written, the article suggests too many medical treatments are crap shoots, when that just isn't the case.
Suppose we learned a bit more about the mechanism by which aspirin affects heart attacks. Suppose then we only prescribed it to that group. Same drug, but now much more effective. Unfortunately, since aspirin is already proven effective, generic, and dirt cheap, and because we continue to cut funding for basic research, there is no incentive for anyone to learn more about it.
This example holds for cancer drugs, too. We know 5FU works, so we no longer researching the how, the why, or the best delivery mechanism.
As written, the article suggests too many medical treatments are crap shoots, when that just isn't the case.
8
I am not sure why you say medical research "isn't asking the right questions". I worked in medical research for several decades and understanding disease mechanism and drug action were very much at the fore. It is already quite well known how a drug like 5FU works, most research now is focused on making better drugs, not ones that simply try to kill faster growing cancer cells by damaging their DNA. Doing this requires basic research that often may appear to be unrelated to the disease, but could prove important in the long run.
1
Regarding Sarah Palin and death panels two other idiots Dr Senator Howard Dean and noted right wing extremist Noam Chomsky agreed with her
The usual anti-science types show up here to demonize medicine via various paranoias du jour
I enjoy reading these comments, i wonder what an unmoderated board would look like if these pass muster
The usual anti-science types show up here to demonize medicine via various paranoias du jour
I enjoy reading these comments, i wonder what an unmoderated board would look like if these pass muster
SSRI's are another one. They are prescribed like candy, in many cases they are not all that effective, people stay on them for years, and -- among other problems -- they are a huge risk factor for osteoporosis. (Which does increase mortality -- mortality rates increase after hip fractures.)
4
The underlying medical conditions SSRIs are prescribed to treat cause an increase in the risk of osteoporosis. Not exercising, for instance, which is common among the depressed, is a big risk factor.
I see a lot of anti-medication comments posted in response to medical articles. Very few commenters are aware of all of the facts.
I see a lot of anti-medication comments posted in response to medical articles. Very few commenters are aware of all of the facts.
4
There are more questions than answers on psychoactive drugs. Nobody understands mental illness, and nobody has the complete lowdown on how these drugs function in the body and brain. Please take a look at the fascinating blog of Kas Thomas, a high-profile biology/microbiology-educated IT pro, who writes carefully and thoughtfully on these issues:
http://asserttrue.blogspot.ca/2015/01/can-antidepressants-make-you-bipol...
http://asserttrue.blogspot.ca/2015/01/can-antidepressants-make-you-bipol...
2
Life is trial and error.....get used to it.
2
Having a problem with the statistics here. Appears to assess usefulness of aspirin in a population with a 10% statistical chance of a heart attack in the next ten years. That would be 200 people in a 2000 person panel. In two years, a total of 5 people have or would have had heart attacks. Times five that equals 25 in a ten year period. So, the NNT has to be a population less at risk of heart attacks than 10%, or the original estimate is way wrong. Very confusing
Your math is wrong. If 2000 people have a 10% chance over 10 years, then an average of 1% will have a heart attack in a random year. So over two years it's 2%, which is 20 people (not 5).
1
Guess what.
Science and medicine are the new religion.
And in this narcissistic and self-absorbed world, the most important function of ANY religion is to extend MY life and make MY life happy and healthier. So no matter what the statistics may prove, I'm going to keep genuflecting to those advertisements and those "medical professionals" and all those other flim-flam artists who prey on my fears and wants and take, ingest, absorb and otherwise BUY all those miracle cures.
Meanwhile, of course, it is my out-sized fears which are as likely as any malady to end my life early.
Science and medicine are the new religion.
And in this narcissistic and self-absorbed world, the most important function of ANY religion is to extend MY life and make MY life happy and healthier. So no matter what the statistics may prove, I'm going to keep genuflecting to those advertisements and those "medical professionals" and all those other flim-flam artists who prey on my fears and wants and take, ingest, absorb and otherwise BUY all those miracle cures.
Meanwhile, of course, it is my out-sized fears which are as likely as any malady to end my life early.
4
If we spoke instead about making sure that medication spending was cost-effective, we could use the exact same numbers and make the exact same recommendations, but suddenly we'd be talking about "death panels".
How would you like us to talk about making medicine more effective? Should we talk about the patient's interests or the payer's interests (both fairly aligned here)? If we ignore all interests, then how do we discuss the issue in the first case?
How would you like us to talk about making medicine more effective? Should we talk about the patient's interests or the payer's interests (both fairly aligned here)? If we ignore all interests, then how do we discuss the issue in the first case?
If it doesn't work don't do it. We spend 25% of our healthcare dollars in the last weeks of our lives. That's a really bad bet. That's like spending 25% of the cost of your car a week before it gets crushed. We have to confront the moron factor, best represented by Sarah Palin's "death panel" idiot test. How many idiots bought that line of....?
Some comments complain about "evidence based medicine". What's the alternative? a coin flip?
Why all the ink on Aspirin? It's statins that should be under scrutiny. How many lives are saved versus how many livers are impaired, memories impaired, and joints inflamed? How much do we spend on statins each year? What do we save as a result? Medicare spent $18.7 Billion in 2011 on "lipid regulators". For $18 Billion we bought a 3% improvement over placebos in mortality improvements and that at a cost in liver disease, Rhabdomyolysis, memory loss, muscle wasting and arthritis.
Some comments complain about "evidence based medicine". What's the alternative? a coin flip?
Why all the ink on Aspirin? It's statins that should be under scrutiny. How many lives are saved versus how many livers are impaired, memories impaired, and joints inflamed? How much do we spend on statins each year? What do we save as a result? Medicare spent $18.7 Billion in 2011 on "lipid regulators". For $18 Billion we bought a 3% improvement over placebos in mortality improvements and that at a cost in liver disease, Rhabdomyolysis, memory loss, muscle wasting and arthritis.
36
We've developed a computational platform that has virtually screened (using a sophisticated docking algorithm developed by us) all human ingestible small molecules against all protein structures to make predictions of which drug would against which disease in a shotgun manner. Both retrospective benchmarking and prospective in vitro validation have yielded much higher accuracies (two orders of magnitude) relative to traditionally used approaches.
One thing we can do is model all the mutations (variants) in the protein structures of any person's meta-genome (or meta-proteome) and make predictions tailored to the individual. We are also working on incorporating other correlative aspects that may lead to higher accuracy such as sex, age, height, weight, etc. I am currently able to make predictions of which drugs are best for me to take for any indication in rank order and what side effects they'd cause, etc.
The project is called CANDO funded by a 2010 NIH Director's Pioneer Award. Our first major paper on it was published in 2014:
http://www.ncbi.nlm.nih.gov/pubmed/24980786
One thing we can do is model all the mutations (variants) in the protein structures of any person's meta-genome (or meta-proteome) and make predictions tailored to the individual. We are also working on incorporating other correlative aspects that may lead to higher accuracy such as sex, age, height, weight, etc. I am currently able to make predictions of which drugs are best for me to take for any indication in rank order and what side effects they'd cause, etc.
The project is called CANDO funded by a 2010 NIH Director's Pioneer Award. Our first major paper on it was published in 2014:
http://www.ncbi.nlm.nih.gov/pubmed/24980786
5
Thanks for pointing out how much research, including CANDO, is being done to increase our depth of understanding of the human body. From a gazillion of such projects, we just might come much closer to the goal of precise and personalized medicine. I went to the Elsevier link you provided, and read the abstract. Can't say I understood it---my field is the human brain and immunology, and I have retired from clinical practice---but it was cool to read a bit of what is being done. Thanks!
1
If you're a woman there is a really good chance the drug was never tested for females so it's a crap shoot on what's going to happen to you if you take it anyway. Human = Male in the pharmaceutical industry.
37
I have noticed a lot of great websites beginning to democratize medical information. The flow from research to knowledge translation still flows through paywall and expensive subscription journals but is now making its way faster and more legitimately to the general public. For example before now doctors like myself had to rely of uptodate.com and pay an arm and a leg while now I and the rest of the public can access theNNT.com and WikEM.org and get most of what I need to treat patients well.
12
Thanks for the links! I was aware of uptodate.com, but not the others.
1
But try to go to the journals to check a reference and once again you are gouged hard. Online access to most journal articles are $35. So we are left trusting the few who write the articles in UpToDate or Wikipedia without the ability to verify the claim in the summary article. Most articles, I will want to check at least 5 references. That would cost me $175 to check only a few of the sources for one article which will typically have bibliography of 20-200 references.
3
Carol, a Google Scholar search will sometimes let you look at the full text of a medical journal article for free. When that's not available, you can often find a summary for it on PubMed, and then investigate the credentials of the people involved with a separate search.
If you live near a university with a medical school, the library may offer free on-site access to medical databases, even for nonstudents. And if not, you may be able to request photocopies of specific articles from your local public library. (Some lending libraries charge for photocopying, but the fee is usually reasonable.)
I used to be an academic librarian, so that's how I know this stuff.
If you live near a university with a medical school, the library may offer free on-site access to medical databases, even for nonstudents. And if not, you may be able to request photocopies of specific articles from your local public library. (Some lending libraries charge for photocopying, but the fee is usually reasonable.)
I used to be an academic librarian, so that's how I know this stuff.
1
The current difficult example of medical intervention with under appreciated risk benefit ratio is the mammogram. The benefit from the mammogram is not so great as the improved treatment lowers the risk of dying from breast cancer. The new understanding of the bodies ability to prevent some cancers from growing has revealed the new risk of over diagnosis of cancer. I don't know what the calculated benefit of mammograms used to be for the woman at average risk, but the calculated benefit that Welch published in 2014 in JAMA of .05-0.49% lives saved after annual screening with mammograms from age 60 to age 70 is not an impressive figure. Considering that 0.6-2.0% will be diagnosed and treated with surgery, and perhaps radiation and chemotherapy for a cancer that never would have become clinically apparent, makes the small benefit feel even smaller.
We need to know the risks and benefit for all medical tests, studies, treatments and procedures.
We need to know the risks and benefit for all medical tests, studies, treatments and procedures.
15
NNT? more like NNP, number needed to pay.
6
If aspirin is recommended for people with a >10% chance of having a heart attack in the next 10 years, shouldn't the number of people in a 2000-person sample who have a heart attack over two years be more like 10%*2000*(2 years/10 years) = about 40, not 3.6? In that case if a daily aspirin prevents 20% of heart attacks it would prevent more like 8 over that period, not 1. What am I missing here?
2
The example was for those who never had a heart attack. Aspirin prevents 20% of recurrent attacks. It's a different population, high a higher risk for heart attack and therefore benefit.
Thank you for the well thought out article. It's balanced, and I want to respond with balance. I take a daily full size aspirin, and feel I can because this costs about $4 per year and I don't have a sensitive stomach. If this cuts my heart attack risk by 1/4000 per year (based on the articles 1 in 2000 per two years), then the financial cost is $16,000 per avoided heart attack, which sounds like a bargain. I'm also impressed by it's anti-cancer properties, but I understand the risk of cancer is low until you are old, so the NNT is high.
I know that being free to make your own choices improves quality of life, and I will have a can of Coke or a double serving of birthday cake just like anybody. However, let's not let high NNT's make us decide nothing needs to be done. Individual NNT's may be high, but I've seen statistics showing how they add up. Studies comparing the risk of early death between those with health choices in the top quarter of the population to those in the bottom quarter show dramatic differences. Please do understand the statistics, but don't use them as a reason to do nothing.
I know that being free to make your own choices improves quality of life, and I will have a can of Coke or a double serving of birthday cake just like anybody. However, let's not let high NNT's make us decide nothing needs to be done. Individual NNT's may be high, but I've seen statistics showing how they add up. Studies comparing the risk of early death between those with health choices in the top quarter of the population to those in the bottom quarter show dramatic differences. Please do understand the statistics, but don't use them as a reason to do nothing.
6
Even aspirin has its risks, and more is not necessarily better. If I recall correctly, the first large-scale study on the use of aspirin involved full doses of aspirin as opposed to a placebo. The study was interrupted on ethical grounds because it seemed that the full dose of aspirin was great at preventing heart attacks. Then they followed longer-term and found that the overall mortality rate was unaffected. That is, people died less from heart attacks, but more from other causes, like bleeding to death after accidents or surgery.
5
mmmm. probably an interesting study, and I wonder if the initial result stemmed from the profession's lack of interest in understanding attition?
Karl - I believe the dose for your purposes is smaller than a daily full-size aspirin. I hope you chose this path in consultation with a medical professional and keep your doctors informed.
1
This N.N.T. is entirely meaningless unless we define the pool of patients which are being treated beforehand. Are the numbers presented here for general population? They appear to be. But nobody (except maybe Big Pharma) suggests that everyone should be medicated. For instance, if we limit medication to those with a chance of heart attack exactly 10% (as per recommendation), we will get 160 heart attacks instead of 200, with 40 prevented per 2000 treated for N.N.T. 50 and not 2000 as this article seems to suggest. The number will be even higher for all patients with >10% probability. For those with >50% probability the N.N.T. is < 8. Does not look so large now, does it? Of course, the trick is to know who is at risk and who is not to avoid medicating healthy people needlessly (Big Pharma may disagree with that). The scientists seem to have figured that out for heart attacks. Let's hope they can do it for other preventable deceases too.
7
Too bad we're not allowed to investigate NNT's and NNH's for guns.
11
It's also too bad that people don't stick to the topics covered in the articles they choose to comment upon. Dragging politics and/or hot-button issues into every comment section degrades the quality of the discussions, in my not-so-humble opinion.
4
The article was about NNT's for various ailments. Death by gunshot is quite a serious ailment. How is Jim S's comment off topic?
4
The man still has a point.
1
Technology is not the only problem. "Outcome management", measuring patient response to procedures, medication and medical equipment, has never been a priority in our fee-for-service system. Every hospital can tell you how much you paid for an aspirin during your hospital stay in 1985, but they can't tell you whether your surgical site ruptured on the way home, the prescribed medication managed your pain, or the walker collapsed when you hobbled to the drugstore. There is no profit in proving procedures, drugs and equipment are useless. Quite the contrary.
4
"When 20 Heart Attach Survivors Switch to a Mediterranean Diet for Four Years: 1 Death is Prevented" Actually, no deaths are prevented, they are merely postponed.
36
I thinks it great we are having a constructive conversation & yes even venting our frustrations as providers but the simple fact remains that the status quo doesn't work anymore.
I happen to agree that personalized medicine & educating our patients is a worthy goal worth pursuing.
Has anyone got a better solution?
We can't keep griping about our life's passion- without offering viable alternatives.
Great article. We've a ways to go but at least we're sitting at the table. Dr Miller
I happen to agree that personalized medicine & educating our patients is a worthy goal worth pursuing.
Has anyone got a better solution?
We can't keep griping about our life's passion- without offering viable alternatives.
Great article. We've a ways to go but at least we're sitting at the table. Dr Miller
4
How do you propose we make it possible for doctors to spend as long as necessary with their patients? I very much appreciate my doctors, but most of them seem pressed for time.
Thanks for chiming in. I always like it when physicians add constructive material to these discussions.
Thanks for chiming in. I always like it when physicians add constructive material to these discussions.
5
The problem with evidence-based medicine is that our evidence is very low quality. Clinical studies are typically run by the pharmaceutical industry (the only entity capable of doing so). The trial subjects are not representative of real patients. Clinical end-points are designed to demonstrate certain effects to gain regulatory approval and get to market. Trials are run over short periods of time and results cannot be necessarily extrapolated over longer periods.
A potential solution to this is access to data mining on all patients in the real world. However, our health care system (that includes HIPAA and all other kinds of regulations on this kind of research) make collection of quality data virtually impossible.
The danger of "evidence-based medicine" is denial of care wrapped in a quasi-scientific package, but in reality based on garbage.
A potential solution to this is access to data mining on all patients in the real world. However, our health care system (that includes HIPAA and all other kinds of regulations on this kind of research) make collection of quality data virtually impossible.
The danger of "evidence-based medicine" is denial of care wrapped in a quasi-scientific package, but in reality based on garbage.
13
Partially true but still, evidence based medicine is a huge improvement on the alternative. HIPAA does not interfere with data mining and to pretend that it does renders observations about "reality based garbage" throw away quips that are of no value. What should replace "evidence"?
1
Sorry, Joseph Huben. Being a physician-scientist, I would be the last person to be against evidence. However, "evidence-based medicine", even though around for decades, suffers from very low quality data. As someone who actually does medical and clinical research, I can say that the vast amounts of data that could solve this problem are not accessible. The reasons are many, including lack of funding, HIPAA, fractured and poorly designed electronic medical records, lack of relevant data capture in the records, etc. However, what I have seen as a physician on the ground is denial of care based on so-called evidence that assumes that real patients, with all their unique problems not captured by any large studies. Too much of "evidence based medicine" is garbage in and garbage out.
10
Cheaper generic drugs may have the same active ingredient as the more costly brand name medication but they are not always effective. The delivery system is what counts. The delivery system is what gets the drug working in your body.
Case in point: the generic "rescue inhaler" proair is well known to be ineffective in a significant number of people, and less effective than the brand name delivery system. This medicine is intended to open the lungs in an asthma attack, in other words it is a first line of defense in a life threatening situation. But the drug is delivered in a crystalline, powdered form with other fillers. The powder can severely irritate the lungs and actually cause bronchospasms. but when the drug is administered as liquid mist it is effective and a life saver.
Case in point: the generic "rescue inhaler" proair is well known to be ineffective in a significant number of people, and less effective than the brand name delivery system. This medicine is intended to open the lungs in an asthma attack, in other words it is a first line of defense in a life threatening situation. But the drug is delivered in a crystalline, powdered form with other fillers. The powder can severely irritate the lungs and actually cause bronchospasms. but when the drug is administered as liquid mist it is effective and a life saver.
13
Cheaper generics are not always as effective because of the placebo effect, as Dan Ariely has demonstrated. The real issue is how stupid are Americans to pay 400% more for prescriptions than Canadians and Europeans? How corrupt is our Congress when it passes laws that prevent our government from bargaining with drug companies for the best price. Why do we pay so much more for healthcare and get worse results? Corrupt Congressman, drug company propaganda and stupid Americans who believe that they are better and smarter than Europeans who pay half what we pay for better care? Or maybe if we just believe in our "best healthcare" shills in Congress and stooges on FOX we can bankrupt Medicare.
11
Absolutely true. I must take several medications for a complex of chronic illnesses, including asthma. As each of my medications becomes "generic eligible", I have to go through a trial and error process to find which of the available generic manufacturers actually works for me (since my insurance won't cover a brand name if a generic is available.)
When rescue inhalers were required to change the method of propellant to protect the ozone, my asthma went severely out of control after being changed to a new delivery system. I went through three different brands of albuterol inhalers before finding the one that worked for me when having an actue attack (Ventolin). I have the middle class means to keep trying inhaler after inhaler to find what works even if I pay out of pocket, but what about the single moms with asthmatic kids who can't afford to try different brands and are forced to use the Proaire that isn't as effective?
When rescue inhalers were required to change the method of propellant to protect the ozone, my asthma went severely out of control after being changed to a new delivery system. I went through three different brands of albuterol inhalers before finding the one that worked for me when having an actue attack (Ventolin). I have the middle class means to keep trying inhaler after inhaler to find what works even if I pay out of pocket, but what about the single moms with asthmatic kids who can't afford to try different brands and are forced to use the Proaire that isn't as effective?
15
A lot of people are noticing generic drugs often are now very expensive. This is because Big Pharma buys up the generic companies or makes deals with them, and so generics that a few years ago were just a few dollars are hugely expensive now. This should simply not be tolerated. But in this country, what Big Pharma wants, Big Pharma gets, with no constaints.
6
Austin raised an important point that was not adequately addressed, so I want to re-visit it. An NNT comes with a duration of treatment, and for some treatments usually quite short relative to a person's life. Extending the use of aspirin 10 or 20 years could likely lower the NNT (the same with statins, Mediterranean diet, etc), but we rarely have that data because RCTs don't extend that far. The response by Dr. Newman citing the Japanese study about aspirin makes no sense to me. Assuming I found the cited study, there was no significant difference in aspirin vs no aspirin groups (not a diminished effect, but no effect). The Asian population is likely different from other studied populations (eg higher hemorrhagic stroke risk and much lower cardiac event rates) and there were important methodological problems with that study (the study was not blinded and did not have a placebo control, the drop-in rate and rate of patients lost to follow-up was high). Also the NNH argument does not hold well, especially for an intervention like the Mediterranean diet. The NNT is likely to be lower over a larger period of time. Also comparing NNH with NNT indeed is important, but it is an apples/oranges comparison because a GI bleed from aspirin is not the same as a heart attack (there is a different value attached by different people.
12
Actually, because in America there is no integration and standardization of electronic medical records and billing software, America has virtually no statistics which reveal clinical outcomes according to any variables.
The four clinical outcomes (prevention, medical, surgical and palliative) are the only products manufactured and produced by health care providers and institutions with their patients. Yet, health care in America is the only industry in the world which doesn't tabulate the quality and price of those outcomes according to any variables.
Therefore, we in America do not know who the best doctors and hospitals are and what are the best diagnostics and treatments for which patients.
Yes, as the article demonstrates we do have some statistics for a few diseases and a few patients. But since America refuses to integrate and standardize electronic medical records software and tabulate and reveal clinical outcomes according to all variables (age, sex, weight, meds, other diseases, income, locale, etc.)we'll never really know who are the best docs and hospitals or what are the best diagnostics and treatments for which people.
Obama and the HHS should think twice about forcing patients onto ACO's and Capitated HMO's in two years and instead integrate and standardize medical records to reveal outcomes in order to enhance the quality and efficiency of health care in America.
The four clinical outcomes (prevention, medical, surgical and palliative) are the only products manufactured and produced by health care providers and institutions with their patients. Yet, health care in America is the only industry in the world which doesn't tabulate the quality and price of those outcomes according to any variables.
Therefore, we in America do not know who the best doctors and hospitals are and what are the best diagnostics and treatments for which patients.
Yes, as the article demonstrates we do have some statistics for a few diseases and a few patients. But since America refuses to integrate and standardize electronic medical records software and tabulate and reveal clinical outcomes according to all variables (age, sex, weight, meds, other diseases, income, locale, etc.)we'll never really know who are the best docs and hospitals or what are the best diagnostics and treatments for which people.
Obama and the HHS should think twice about forcing patients onto ACO's and Capitated HMO's in two years and instead integrate and standardize medical records to reveal outcomes in order to enhance the quality and efficiency of health care in America.
17
Not to mention psych drugs which can lead to psychosis, suicide, murder, relentless akathisa, diabetes, high blood pressure, and tardive dyskinesia. In most case they are no better than placebo.
5
Once again, generic versions of the psychotropic drugs are usually the culprits because the "fillers and binders" used by different manufacturers mean that concentration in the blood stream is achieved at different rates-- so the therapeutic dose may not be reached using one version of the generic, while the patient may be over-medicated on a different generic version of the same medication. This is why many psych doctors insist on prescribing only brand name meds.
2
The studies that purport to show that antidepressants are no more effective than placebos focused on older drugs. And letting serious depression or other mental illnesses go untreated can also lead to suicide, murder, lifestyle choices that lead to poor heart health, etc.
Psychotropic medications aren't perfect, but they're not evil incarnate, either. I take one that keeps me from having epileptic seizures. Oh, and Julia: It's a generic.
Psychotropic medications aren't perfect, but they're not evil incarnate, either. I take one that keeps me from having epileptic seizures. Oh, and Julia: It's a generic.
3
I think precision medicine presents the public with an difficult choice. On one hand we could have a truly integrated healthcare model that tracks the efficiency/efficacy of treatments over time continuously.
The other side is deciding if we are ready for that much of a big-brother approach to healthcare. Aside from the expense and the impracticalities of trying to prevent for-profit companies form gaming the system, we have to decide if we want that much of our privacy irreversibly captured by technology. It opens the door for all kinds of social problems. And we're all slowly but surely drifting towards that.
And while we are wandering down that road, we miss out on some simpler, lower cost, more practical public health options. We've all but abandoned the idea of truly preventative medicine due to the fact that treatment pays better than prevention. That's great for hospitals, doctors and pharma companies. That's bad news for us patients!
And let me throw another wrinkle in: I propose that increasing literacy and writing skills in the general public can affect health outcomes. Which kids would be healthier: those who receive a billion dollars of literacy/writing programs or a billion dollars of healthcare?
The other side is deciding if we are ready for that much of a big-brother approach to healthcare. Aside from the expense and the impracticalities of trying to prevent for-profit companies form gaming the system, we have to decide if we want that much of our privacy irreversibly captured by technology. It opens the door for all kinds of social problems. And we're all slowly but surely drifting towards that.
And while we are wandering down that road, we miss out on some simpler, lower cost, more practical public health options. We've all but abandoned the idea of truly preventative medicine due to the fact that treatment pays better than prevention. That's great for hospitals, doctors and pharma companies. That's bad news for us patients!
And let me throw another wrinkle in: I propose that increasing literacy and writing skills in the general public can affect health outcomes. Which kids would be healthier: those who receive a billion dollars of literacy/writing programs or a billion dollars of healthcare?
2
Considering how much information companies collect about us now, I think the "protecting our privacy" horse has already left the barn.
I appreciate your last point, however. It seems like many Americans (including some journalists and doctors) don't know how to make sense of all of the statistical information available to them.
I appreciate your last point, however. It seems like many Americans (including some journalists and doctors) don't know how to make sense of all of the statistical information available to them.
2
As a healthcare "insider", I have rarely witnessed all that personal health and demographic information used in any kind of coherent manner related to healthcare.
We have big-brother potential and perhaps that endpoint is inevitable, but we are not yet close to the kind of large scale social control that could eventually come from it.
We have big-brother potential and perhaps that endpoint is inevitable, but we are not yet close to the kind of large scale social control that could eventually come from it.
1
"But still, seven of eight people suffering an asthma attack see no benefit at all from steroids with respect to preventing hospitalization."
Preventing a one out of eight expensive ER hospitalization makes the 8:1 ratio socially and economically for everyone. It saves a huge amount of money on everyone's health care bill.
But 100% of the people benefited from the treatment yet the NNT gives a the 100% effective treatment barely an effective rating.
Preventing a one out of eight expensive ER hospitalization makes the 8:1 ratio socially and economically for everyone. It saves a huge amount of money on everyone's health care bill.
But 100% of the people benefited from the treatment yet the NNT gives a the 100% effective treatment barely an effective rating.
2
"But 100% of the people benefited from the treatment yet the NNT gives a the 100% effective treatment barely an effective rating."
It's not quite that simple. 100% of the people may have benefited economically, but 7 of those eight people took a potent drug without benefiting from it. Short courses of steroids are usually well tolerated. But occasionally people do have side-effects: mood changes, insomnia, irritability, etc.
It's not quite that simple. 100% of the people may have benefited economically, but 7 of those eight people took a potent drug without benefiting from it. Short courses of steroids are usually well tolerated. But occasionally people do have side-effects: mood changes, insomnia, irritability, etc.
2
We don't know how many benefitted from the treatment, just how many hospitalizations were avoided. If one's wheezing and shortness of breath improve with a short course of steroids, in general it's worthwhile. Similarly, adhering to a Mediterranean diet may only prevent relatively few deaths, it doesn't mean the overall health and quality of life wouldn't be better for a much higher percentage of people eating that diet. You have to look carefully at the outcome being measured in these studies, which often isn't the only objective for which the treatment is prescribed.
13
NNT doesn't take into account the other health problems that can crop up from repeated cycles of steroid use. Steroids work to reduce inflammation in the lungs, but at the expense of other body systems. Weight gain, overall lowering of immunity, and mental health side effects are quite common in patients who have to go through repeated cycles, increasing risk for heart disease, infections, kidney problems, and suicide, among others.
3
Although extremely useful, evidence based medicine is not yet ready for prime time. This is because evidence based medicine is only available for a small fraction of medical conditions. In other words, if we were ready to practice ONLY evidence-based medicine today, we would be assuming that any further medical research is unnecessary. For example, there were never any studies to show that phenytoin (one of the first drugs used to treat epilepsy) was more effective than placebo. However, its frequent use was sanctioned by clinical observations (patients given phenytoin had less seizures than when not treated). The same was true for several antibiotics and for many medical therapies still available today. We are far from having the statistical knowledge and the research backing up many useful therapeutic modalities available. However, it is unfortunate that in the name of evidence based medicine (or the lack of it), many insurance companies frequently deny payments for patient care.
16
One of the most important lessons I learned in medical statistics is this:
The risk to the individual is always 1 or 0.
If it's my heart attack that is prevented, I then I probably think it is all money well spent.
The risk to the individual is always 1 or 0.
If it's my heart attack that is prevented, I then I probably think it is all money well spent.
20
Especially when it is not *your* money being spent.
Importantly, every treatment has a potential side effect. You may (hypothetically speaking) be the one person where a heart attack is prevented, but you might also be the person who gets a bleed in the brain from a simple slip and fall.
Every treatment has a benefit and a side effect, and weighing the side effects is just as important!
Every treatment has a benefit and a side effect, and weighing the side effects is just as important!
1
This is not the right way to think about it. Your outcome is 0 or 1. It is helpful to know that, for example, if 100 people exactly like you took a particular drug, 99 died in their sleep. Although you will be a 0 or a 1, that piece of risk information was extremely informative to you.
Unfortunately, this is an example of confused language. Taking the aspirin numbers verbatim, in a cohort of 2000 at-risk people the baseline incidence rate for a heart attack is 4.6 people or 0.23% (because 100*4.6/2000 = 0.23%). The incidence rate after administration of aspirin drops to 3.6 people or 0.18% (i.e., 100*3.6/2000 = 0.18%). That's a 22% reduction from the baseline incidence rate. For a small country the at-risk population can be hundreds of thousands; for a large country millions or tens of millions. With such numbers aspirin's effect becomes, in fact, very large.
I followed the link provided within to the summary of the aspirin study (http://www.thennt.com/nnt/aspirin-to-prevent-a-first-heart-attack-or-str..., and it is equally problematic. It refers to different endpoints (the NNT is timepoint-dependent). And, it offers incoherent conclusions: First we learn that "Aspirin works to reduce events among patients who have a higher likelihood of having an event" but just a short space later if flatly contradicts that: "However the potential for aspirin to be beneficial in this group remains largely speculative … and there was no demonstrable benefit to aspirin even for these patients (though this subgroup was small in these trials)."
That's not to deny the validity of the NNT; the point is that the NNT has some very specific constraints and that some caution must be exercised when drawing population-wide inferences from samples.
I followed the link provided within to the summary of the aspirin study (http://www.thennt.com/nnt/aspirin-to-prevent-a-first-heart-attack-or-str..., and it is equally problematic. It refers to different endpoints (the NNT is timepoint-dependent). And, it offers incoherent conclusions: First we learn that "Aspirin works to reduce events among patients who have a higher likelihood of having an event" but just a short space later if flatly contradicts that: "However the potential for aspirin to be beneficial in this group remains largely speculative … and there was no demonstrable benefit to aspirin even for these patients (though this subgroup was small in these trials)."
That's not to deny the validity of the NNT; the point is that the NNT has some very specific constraints and that some caution must be exercised when drawing population-wide inferences from samples.
23
You are right. The question of whether a treatment should be recommended to the public is different from the question of whether individual X (e.g., me) should get the treatment. In my experience, physicians often base individual recommendations (for which the NNT is highly relevant) mainly on statistics relevant to public health outcomes. That's why I'm glad to see this article's emphasis on and clear explanation of the NNT.
2
This is surely correct, but when one has to think only about himself or herself, then NNT is far more useful. As the example with the Mediterranean diet makes clear, does one really want to stay on a specific diet for four years without any slips when the odds of it having the desired effect (keeping me alive) is only 1 in 30?
For some, this makes perfect sense, but for many, the calculation may be that their quality of life disintegrates too much for it to be worthwhile. Having this information, one can better make decisions about their own personal choices. After all, I care very little what happens to the rest of society when I'm looking at my personal health and the decisions I've got to make to maintain it.
For some, this makes perfect sense, but for many, the calculation may be that their quality of life disintegrates too much for it to be worthwhile. Having this information, one can better make decisions about their own personal choices. After all, I care very little what happens to the rest of society when I'm looking at my personal health and the decisions I've got to make to maintain it.
Aspirin's effect becomes very large only if everyone takes aspirin.
Statistics can be very misleading. Consider an often used statistic: median lifespan (half the people live less than the median lifespan and half live more). How much does a particular treatment increase the median lifespan? Consider the following (contrived) example. Suppose there are 2001 people with a particular disease. Without treatment, 1000 of them die in 1 year, one dies in 2 years, and 1000 die in three years. The median lifespan is 2 years. Now suppose they are all given treatment, and after the treatment, 1000 die in 1 year, 1 dies in 2 years, and 1000 are completely cured and live forever. The median lifespan is still 2 years, even though (almost) half of the people were cured. If the increase in median lifespan were used to evaluate that treatment, the answer would be that the treatment was worthless and should never be used. That's a contrived example, but many real world situations are not too different. So we have to be careful how we decided whether or not to use some treatment based on increase in median lifespan or other statistics.
4
Or just don't use median lifespan as the basis for selection.
Yes. This is why I get frustrated when I see a "Well" blog post about a study that says it showed that "Doing _________ raised people's risk of __________ by five percent," without listing what the original numbers were. An increase of five percent when the baseline risk was half of a percent is quite a different thing from an increase of five percent when the baseline risk was ten percent.
4
I frequently refer to the NNT for patients, especially when considering long term treatments like for cholesterol lowering and high blood pressure. The problem with the clinical utilization of the NNT is the studies are not carried out long enough (too expensive to do so). Many of the newer trials are stopped as soon as there is evidence of some positive effect (a divergence) that is statistically significant (defined as very unlikely to occur by chance alone). Those trials make it very difficult to establish a useful NNT. If I were a patient, that would be the first thing I would ask if a doctor wanted to put me on a medication. The number crunching needed to create that very handy link in the article was a huge undertaking, and we owe the researchers thanks. There is also growing evidence that many of the old studies that showed positive effects are less repeatable, showing a regression to the mean and less effect over time. THIS is the reason we need the precision medicine; it is EXACTLY what has been missing all along: we can tailor medication regimens to a persons genetic tendencies and lifestyle, or completely avoid medications altogether in some.
7
In a way, the argument to pursue "precision medicine" is a bit silly - isn't the science of medicine trying to do this all the time? The fact that it has only been partially successful so far doesn't mean that pursuing it is really a new concept. Nonetheless, the idea of "precision medicine" being discussed widely by many biomedical institutions is based on the hope to get better at using genomic data to improve what we'e always been trying to do. This idea was first named, widely, personalized medicine, but the more realistic term "precision medicine" has come into vogue. More realistic because it continues to pursue what we have always tried to do, using new advanced tools and data. The ideal of a completely personalized medicine would be very difficult and extraordinarily expensive to realize - one cannot hope to expend resources developing new therapeutics for an individual.
4
Actually, the "science of medicine" is largely about selling drugs. Kind of like the pusher in the alley around the corner.
In an effort to make your point, you've used unrealistic time frames: we are not at risk of heart attacks for only two or four years or five. Given that the risk persists and grows with time, both aspirin and the Mediterranean Diet are likely a good deal more effective than you suggest. It is also true that treatments can often be combined to greater effect; diet, excercise, stopping smoking, aspirin, and where necessary drugs like statins can all reduce heart attack rates. If that weren't the case, we wouldnt have had the success that we have at slashing cardiovascular mortality. Similarl, while you rightly point out that antibiotics are overprescribed, that is a seperate issue; prescribed correctly, antibiotics are reliable lifesavers.
That being said, it is clear that medications are in may cases overused.
That being said, it is clear that medications are in may cases overused.
21
The time intervals reported are all they have the data for; no one will pay enough money to look at them for longer. It is entirely possible they will all regress to the mean, as many studies have shown (meaning the effects eventually taper off over time).
The medical industrial complex is equivalent to an organized crime syndicate, out to make money for all concerned including pharmaceutical firms, doctors, hospitals, HMOs etc. The American public is being bilked.
It would terrify the average citizen if he or she knew what really goes on. I know because I am "behind the curtain".
It would terrify the average citizen if he or she knew what really goes on. I know because I am "behind the curtain".
15
Your point about short time frames is well taken. However, the authors used these periods of time not for emphasis but because the clinical studies in which the data were collected only ran for those period of time. It is extremely unusual to run a clinical trial for 10 years, let alone 20 or 30 or more and one can not extrapolate beyond the length of the actual data collection period.
3
An obvious approach is to standardize health records including genetics, lifestyle, life circumstances, environmental exposures and medical treatment. Such data can then be mined. It's likely that some answers will emerge in time. Perhaps many answers. We are beginning to progress in this direction but slowly, very slowly.
The process of designing and implementing a well-designed database system will involve a great deal of work and smart collaboration. However, it ultimately is a relatively straightforward process. A pilot process with ongoing adjustments will be quite helpful.
What might not be straightforward is how to navigate the endless contention and resistance which is so much a part of our public discourse now. In response to our difficulty with the concept of common purpose I hear the choruses of that tiresome and mostly meaningless refrain: "Human nature!". The well worn one-size-fits-all excuse! We tend to be disinclined to accept excuses from our children when it comes to their homework and toothbrushing and restraint of violent impulses. How about ourselves? Are the political and medical establishments ready for progress? Or would be prefer delays and gridlock. Same idea applies most any project... Improving the economy, protecting the environment, protecting the security of our citizens... you name it!
The process of designing and implementing a well-designed database system will involve a great deal of work and smart collaboration. However, it ultimately is a relatively straightforward process. A pilot process with ongoing adjustments will be quite helpful.
What might not be straightforward is how to navigate the endless contention and resistance which is so much a part of our public discourse now. In response to our difficulty with the concept of common purpose I hear the choruses of that tiresome and mostly meaningless refrain: "Human nature!". The well worn one-size-fits-all excuse! We tend to be disinclined to accept excuses from our children when it comes to their homework and toothbrushing and restraint of violent impulses. How about ourselves? Are the political and medical establishments ready for progress? Or would be prefer delays and gridlock. Same idea applies most any project... Improving the economy, protecting the environment, protecting the security of our citizens... you name it!
3
What is the NNT for prevention? 20-30 minutes a day of vigorous exercise? Controlling one's weight before the heart attack or stroke? Not smoking cigarettes? Controlled alcohol usage? Not driving under the influence? Not driving distracted? Using seatbelts? Controls on teen driving? Finishing high school?
Those are the stats Obama should be focusing on, but that wouldn't garner any votes. An ounce of prevention is indeed worth a pound of cure.
Those are the stats Obama should be focusing on, but that wouldn't garner any votes. An ounce of prevention is indeed worth a pound of cure.
29
Smithaca is of course correct. But getting these NNTs is a huge problem in operational definition, data collection, and self-selection bias.
1
You only want to gather data if you can use the data, and people who make bad personal decisions like drunk driving already don't care about doing cost-benefit analyses. Therefore, it makes more sense to spend resources on gathering data that will be used to change decisions, like data for prescribing medications, because doctors do care about whether the benefits of prescribing X to the patient outweigh the negative impacts X's side effects have on the patient.
A little more background is needed on how the statistics are compiled. Example:
out of 2000 people taking aspirin, supposedly 4 have heart attacks anyway. But it follows that 1996 DON'T. So how does one know that the aspirin DIDN"T prevent those 1996 who didn't?
The logic is a little perplexing: how can you say that a treatment wasn't responsible when something bad never happened? Isn't that just trying to prove a negative?
out of 2000 people taking aspirin, supposedly 4 have heart attacks anyway. But it follows that 1996 DON'T. So how does one know that the aspirin DIDN"T prevent those 1996 who didn't?
The logic is a little perplexing: how can you say that a treatment wasn't responsible when something bad never happened? Isn't that just trying to prove a negative?
6
The data for the NNT for this particular example is compiled from a meta-analysis published in the Lancet in 2009. In all of the trials included in this meta-analysis, two groups were compared: those who received aspirin and those who didn't. In that way, the treatment effect for the variable of giving aspirin can be seen. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2715005/
The way that randomized control trials or cohort trials work is that they would simultaneously look at 2000 people NOT taking aspirin. In both the 2000 people taking aspirin and in the 2000 people NOT taking aspirin there would be 1,996 people who didn't have a heart attack. That's how they know that aspirin isn't preventing heart attacks in most people.
Because there was most likely a control group of 2000 other people not taking aspirin who were similarly at risk and 1996 of them didn't have heart attacks, or some percentage of that. Rather, hopefully they designed the study that way.
As others have alluded to, the catch with NNT and NNH is that they are not tailored to individual patients. Depending on a patient's profile, his or her NNT might be much greater or lower than the overall value. Personalized medicine would thus be better served by personalized predictions that take into account individual characteristics.
3
Become an Anesthesiologist.
Most the major drugs have a NNT of 1: Given the right does of proposal, 100% of patient become unconscious! Give a medication to raise or lower the blood pressure, NNT near 1. Even the "weak" anti-nausea medication have a NNT in the range of 3-6.
Most the major drugs have a NNT of 1: Given the right does of proposal, 100% of patient become unconscious! Give a medication to raise or lower the blood pressure, NNT near 1. Even the "weak" anti-nausea medication have a NNT in the range of 3-6.
8
In the aspirin example, the recommendation was to take aspirin if the individual had a calculated risk of more than 10% of having a heart attack. But of the 2000 NNT, only 3.6 actually have a heart attack, which is far less than 1%, so either the majority of the 2000 people in this group do not meet the high risk criteria, or the calculation of the risk factor is grossly incorrect, or something else is wrong with the story.
1
Exactly. Those aspirin numbers make no sense. If one follows the recommendation that only those whose chance of getting a heart attack in the next 10 years is 10% should take aspirin, out of those 2000 at least 200 (10%) should have a heart attack if they do not medicate. 200 is much more than 5. Were the same 2000 to take a daily dose of aspirin only 160 would still have a heart attack, with 40 heart attacks prevented by the medicine. Not such a small number as we are lead to believe. Should we change the recommendation to medicate only those with 50% chance of a heart attack, then, assuming the same prevention efficiency, we would prevent 250 heart attacks among the same-size 2000-strong cohort of patients. Sure, medicating healthy risk-free people does not prevent any decease. Are we supposed to be surprised here? Some very sloppy reporting by NYT.
While it seems like 0.5% success in the case of aspirin for heart attacks seems low, considering the severity of a heart attack, it's not bad. In terms of the other treatments, I think those are actually some high percentages. While those treatments certainly aren't perfect, this article actually makes me think that if I had a predisposition for any of those conditions or had one of those conditions, I'd actually take the drug outlined in this article. I think other factors are more compelling detractors, such as comparative risk factors or side effects.
1
Gastric bleeding, a very real risk of daily aspirin therapy, isn't anything to sneeze at.
Going to the doctor and asking for an antibiotic for a (probably viral) sinus infection isn't smart. I usually get at least one sinus infection a year, and I don't visit a doctor to get it treated unless there are clear signs that I've gotten a secondary bacterial infection. The overuse of antibiotics is a threat to everybody's health, because it increases the number of infections that can't be cured with any commonly available antibiotics.
When it comes to medicine, "more" doesn't always equal "better."
Going to the doctor and asking for an antibiotic for a (probably viral) sinus infection isn't smart. I usually get at least one sinus infection a year, and I don't visit a doctor to get it treated unless there are clear signs that I've gotten a secondary bacterial infection. The overuse of antibiotics is a threat to everybody's health, because it increases the number of infections that can't be cured with any commonly available antibiotics.
When it comes to medicine, "more" doesn't always equal "better."
1
Agreed, stomach and intestinal issues are a very real possibility while taking aspirin, among other pain-killer type medicines. I wouldn't take antibiotics yearly, however, if I have an infection, i would take them. I definitely don't think more is better. I actually tend to shy away from medication. I don't think that my post implies that more is better. Rather, I'd like to just point out that this particular article doesn't bring up side effects (such as gastric bleeding) which are better reasons to not take drugs, than these statistics.
1
Thank you for the clarification, Sue. Go Blue!
Thanks for a cogently and logically written article.
It was always clear that doctors are experimenting when prescribing. The odds of success is directly proportional to the time a doctor spends talking with the patient because those conversations provide the clues to "personalizing" prescriptions. This aspect of healthcare has been getting more attention (which it deserves) and needs to be included in the metrics used by insurance companies.
It was always clear that doctors are experimenting when prescribing. The odds of success is directly proportional to the time a doctor spends talking with the patient because those conversations provide the clues to "personalizing" prescriptions. This aspect of healthcare has been getting more attention (which it deserves) and needs to be included in the metrics used by insurance companies.
16
And here is the big problem: no, the insurance company does NOT get to tell me that a treatment that MIGHT save my life will not be covered because of a beancounters NNT calculation. The insurance company should NOT be a part of the equation.
3
I do not know about "cogently" but being "logically written" is not among the merits of this article. The math presented here is somewhere between "confusing" and "misleading". Here is a question for you: How is among the 2000 patients with >10% chance of a heart attack (those for whom a daily dose of aspirin is recommended) only 5 do get a heart attack without medication? The actual number is, of course, much larger. At least 200, in fact, assuming all 2000 have 10% chance and much larger in reality, considering that many would have even higher probability.
If the insurance company has a limited amount of money, shouldn't they spend it in the way expected to maximize quality-adjusted life-years?
Put more simply, if the money spent on a treatment with a low chance of saving your life could instead be spent on a treatment with a higher chance of saving someone else's life, or treatments with the same chance of working as yours that could save 2 lives, isn't that a better outcome because it leads to fewer deaths on average?
If the decision that saves the most lives/QALYs on average is not the best decision, please tell me how the insurance company should decide how to allocate resources.
Put more simply, if the money spent on a treatment with a low chance of saving your life could instead be spent on a treatment with a higher chance of saving someone else's life, or treatments with the same chance of working as yours that could save 2 lives, isn't that a better outcome because it leads to fewer deaths on average?
If the decision that saves the most lives/QALYs on average is not the best decision, please tell me how the insurance company should decide how to allocate resources.
One cannot but be amazed by the brilliance of our President. He is a lawyer but he understands numbers and medical terminology as though he is an actuary or a physician. Precision Medicine - how futuristic! I am going to take the bait for aspirin. As mentioned only one in 2000 will have myocardial infarction prevented. However, I am witness ( I sedate patients for upper endoscopy ) to the gastritis present in almost all the patients taking aspirin (even baby aspirin ). Which means 2000 people suffer from gastritis to prevent myocardial infarction in one patient. Talk of absurdity! But one cannot blame the medical professionals alone because they have to practice defensive medicine.One has to order as many tests and prescribe as many medicines just so all bases are covered to prevent litigation and loss of license which would mean the end of his career and his reputation.
38
to SI
as much as I find "precision medicine" a bit "absurd", I also find your justification of useless medical practices a bit absurd. Doing everything on everybody 1) does not prevent a lawsuit 2) it degrades medicine to knee jerk ministration of procedures and treatments 3) it allows doctors to blame others (legal system) for their "one size fits all" unskilled medical practices.
It is time that we grow up.
By the way, I have been in practice for 30 years
as much as I find "precision medicine" a bit "absurd", I also find your justification of useless medical practices a bit absurd. Doing everything on everybody 1) does not prevent a lawsuit 2) it degrades medicine to knee jerk ministration of procedures and treatments 3) it allows doctors to blame others (legal system) for their "one size fits all" unskilled medical practices.
It is time that we grow up.
By the way, I have been in practice for 30 years
5
I will have to disagree with your "fact" that all 2000 people taking a baby aspirin will end up with gastritis. Gastritis is caused by many things including stress and poor diet. Using your correlation, you could blame the gastritis on things that all of do every day. That is not how a scientific study is performed.
2
And that is why the "me too" drugs that are constantly derided aren't really me too drugs. Because one drug within a class may not be suited to an individual, having multiple alternatives are worthwhile. One could be allergic to Zoloft but not to Wellbutrin or vice versa. Even within a class side effects are different for different patients.
9
While zoloft and wellbutrin are both antidepressants, they are not chemically similar and work in different ways.
1
Exactly, which is why I said, "even within a class side effects are different for different patients". So while I did not cite 2 SSRI's the same logic would apply to two SSRI's, or ARB's or CCB's.
this stuff is all interesting, but still maddeningly imprecise. in the first instance, a more compelling metric might be how many heart attack deaths are avoiding by folks talking aspirin. My heart attack victims, I believe, survive, so the math would be much less compelling. As I understand it we're talking about the consumption of nearly 1.5 million aspirin here. And, of course, our metric for people who are at risk of having a heard attack isn't that precise either.
4
I remember first learning about NNT in school. It really puts into perspective how good our bodies are at healing themselves. A NNT should be readily available to the public for every prescribed drug and every proposed procedure. We are trying to move from the realm of standard practice to evidence based medicine. What is the point of conducting all of these very expensive time and labor intensive studies if we do not pass the information along to the public? Good article.
67
When a person comes under the care of America's de facto criminal health care system (pre ACA), many, many people die.
Look at our vital stats like life exp., infant mortality rates etc...standard of living...ie..many of our peer countries have caught us and surpassed us...
Look at our vital stats like life exp., infant mortality rates etc...standard of living...ie..many of our peer countries have caught us and surpassed us...
10
Yes, let's do that Paul. Those stats are skewed. Those countries do not include deaths from murder & violence as we do. Their definition of infant mortality begins days after birth unlike ours. And life expectancy stats differ because America is the only country with the enormous obesity problem that contributes to poor health. That is not a fault of our healthcare system but of Americans and their poor choices. I suggest you educate yourself beyond the NYT articles before making sweeping statements.
10
Putting aside the unnecessary sarcasm, I imagine the reason many countries don't include deaths from murder and violence is because they don't have the stats to include that we do (thanks to our abundance of guns).
16
Agreed Anne...we live in a great country but nobody is perfect. Our de facto criminal (pre ACA) health care program and our national cultural gun sickness are two stains on this great country.
4
If I am the asthmatic who stays out of the hospital because I am treated with steroids, I want steroids. I know steroids' side effects, the probable, possible and the remote. I am not just a statistic, I am a person with responsibilities to others and I would like to be able to accomplish things that cannot occur from a hospital bed.
16
If you have a medical reason for T and are prescribed it then there is no reason to avoid the hospital. In my opinion any other off label use is needlessly dangerous. Like saying I know the risk of smoking but I'm not a statistic
2
@jb - But don't you think there's a difference between people making an informed choice with knowledge of both the pros and cons of taking certain meds (or undergoing certain treatments) in regard to their life situation and doctors simply handing out pills without regard to how many people they are likely to help? Personally, I avoid steroids and have a friend who felt her life was being destroyed by steroids taken for her asthma (she ended up confined to a wheel chair until she, against her doctor's advice, weaned herself off of them). But were I in your situation, I might feel differently. To me, the problem is that there's little attempt to analyze the situation on a person-by-person basis and to help people make the best decision (sometimes between two not-very-good choices) for them.
President Obama--Stay out of my office! As a psychotherapist of 30 years in private practice who accepts insurance, our Medicare reimbursements have increasingly plummeted. Now we are being asked to add additional info referred to as the PQRS. The info from PQRS will be used to decide when, what type of TX & how many sessions etc. the government will eventually reimburse. In the meantime, if you haven't already participated, Medicare as of this year, has reduced your already reduced reimbursement by 2% and plans to increase that penalty incrementally in successive years.
Therapy is NOT a precise science Mr. President. So much of it also depends upon the nature of the relationship, the evolving trust between therapist & patient, as well as the clinician's skill. Try to package that Mr. President. All you will come with are more & more therapists as well as doctors leaving Medicare. We entered these helping professions to heal. Much of it is ART as well as science. You, Mr. President are reducing it to mere economics. Clearly, your ACA guru was an MIT Economics professor. Government doesn't belong in the therapeutic relationship. And you don't belong in my office. Stay out!
Therapy is NOT a precise science Mr. President. So much of it also depends upon the nature of the relationship, the evolving trust between therapist & patient, as well as the clinician's skill. Try to package that Mr. President. All you will come with are more & more therapists as well as doctors leaving Medicare. We entered these helping professions to heal. Much of it is ART as well as science. You, Mr. President are reducing it to mere economics. Clearly, your ACA guru was an MIT Economics professor. Government doesn't belong in the therapeutic relationship. And you don't belong in my office. Stay out!
20
So stay out of your office - except to pay for the treatment? If you're going to take government money, you're going to have to deal with government restrictions.
46
How much do you charge for a 50 minute visit? As one of the taxpayers who is footing the bill for Medicare reimbursement for psychotherapy, I want to be very sure that the patient is getting value for my and other taxpayers' money. This can only be done with government oversight and regulation. If you don't want to be reimbursed by Medicare then only treat private pay and privately insured patients.
35
But Doctor, you want ME (a taxpayer) to pay for your "ART." I'm willing to pay for science; for art, not so much. If you cannot demonstrate that your art is effective, I suggest that you not demand that I pay for it.
31
What happens when you combine treatments? For example if you are at risk for a heart attack, and you take aspirin, switch to a Mediterranean diet, and modify other risk factors?
Also in the case of aspirin, yes 1/2000 sounds small, but what happens when you extend that out for 10 years. It becomes 1/400, no? Which is not bad considering how cheap aspirin is, and how little side effcts a baby one has.
Also in the case of aspirin, yes 1/2000 sounds small, but what happens when you extend that out for 10 years. It becomes 1/400, no? Which is not bad considering how cheap aspirin is, and how little side effcts a baby one has.
6
Excellent question and point, Austin. We also would have expected this - that the rise in benefits from aspirin is linear over time. Unfortunately, a recent large study from Japan (http://jama.jamanetwork.com/article.aspx?articleid=1936801) suggests that if the time is extended the benefits of aspirin actually disappear, rather than accruing. Also, consider that the harms accrue over time as well, and they typically are linear in their increase. So it's possible we may have over-estimated the benefits with our numbers. - David H. Newman, MD, TheNNT.com
28
Dr. Newman -- you are talking about an RCT done in Japan. I am not an enormous advocate for aspiring for primary prevention either, but with all due deference and respect, do you believe these results are generalizable to a U.S. or Western population? What are your thoughts regarding contamination, viz. those in the no-aspirin group who may well have been taking aspirin during some course of the study? How do you feel physician-patient relationships in an area of the world such as Japan may have influenced reporting of off-study aspiring usage? I find that the authors' dismissal of the so-called "small" effect that this might have the outcome of the trial to be concerning, seeing as little attempt was made to present results from hypothetical scenarios. The reduction in the incidence in colorectal cancer in the group receiving aspirin was also waved off (again, assuming no contamination!) -- also disappointing but forgivable given that it was outside the scope of the primary endpoints of the article. The only thing that is clear to me is that the role of aspirin for primary prevention remains to be strictly defined. At the present time, it is loosely defined and is very obviously drawing the ire of patients who cannot be blamed for wanting more definitive advice from their physicians.
And to complicate it even more if genetic/physiological differences between regions affect the NNT, is it too much to think that the cultures of various regions affect NNT? Attitudes, optimism, expectations, mood, cultural values, outlook: All thee social factors all have a powerful effect on patient recovery rates.
Good article. One suspects all these studies of recent need be refined when and if we get full blown Universal healthcare. Kind of like a prep for rationing care. I find MD's and I know a few practice what they learned in Med school. Example new BP guidelines for seniors didn't change how my GP treat high B/P or the big haring about PSA. My well regarded Urologist sticks with annually PSA and Avodart. Avodart was after approval for BHP was thought to also help reduce Cancer risk. Then the FDA said it may cause Cancer in certain circumstances. I conclude the patient has to be involved in the decision making.
4
I conclude you need to find new physicians.
5
I'll point out that this issue must be considered in the context of a major shift in medicine, from treatment based on numbers (including N.N.T.) to treatment based on the unique characteristics of the patient (including her DNA). Since humans like to think of themselves as unique, guess which approach will appeal to patients and shape public opinion.
2
What unique characteristics are yyou talking about? Upon what evidence would your doctor decide that you would benfit from taking aspirin but the guy in the waiting room wouldn't?
ken h:
Humans are currently recognized to have approximately 30,000 genes. These genes differ among individuals (because of heredity or mutation), such that some drugs are effective in specific individuals but not others.
The promise of pharmacogenomics is to design molecules to interact with specific genes. An effort to sequence genes in an individual can show what drugs will be effective.
Collins, F.S. The Language of Life: DNA and the Revolution in Personalized Medicine. NY: HarperCollins, 2010.
Francis S. Collins, M.D., Ph.D., is the Director of the National Institutes of Health.
Humans are currently recognized to have approximately 30,000 genes. These genes differ among individuals (because of heredity or mutation), such that some drugs are effective in specific individuals but not others.
The promise of pharmacogenomics is to design molecules to interact with specific genes. An effort to sequence genes in an individual can show what drugs will be effective.
Collins, F.S. The Language of Life: DNA and the Revolution in Personalized Medicine. NY: HarperCollins, 2010.
Francis S. Collins, M.D., Ph.D., is the Director of the National Institutes of Health.
4
5barris: unless I've missed something, your number is off by quite a bit. humans have about 20,000 genes--perhaps as few as 19,000--not 30,000.
2
Seems like aspirin is barely worth it, diet is barely worth it, the flu shot is barely worth it. But if you add up all these little advantages, it can make a difference over an 80 year lifespan. There is little chance of a seatbelt helping me if I drive to the store today, but if I never use it, my life expectancy will be cut by an amount that is likely big enough to be worth the bother.
14
No ... flu shots are worth it. You probability of getting the flue is much reduced ... even this year ... compared to any harms from getting the shot.
3
Good points, epistemology (and worthy of your name). But keep in mind that the NNT needs to be right next to the NNH. With seat belts you probably experience little to no harm, so just about any benefits you get probably tip the balance in favor of wearing the seat belt. If we had an NNT summary for seat belts on our website (maybe we should...) it would be labeled a 'Green', because the benefits outpace and outweigh the harms. - David H. Newman, MD, TheNNT.com
11
The article also mentions N.N.H., the number needed to harm. The downside of a regime such as a daily baby aspirin also needs to be taken into account. Aspirin, even in a low dose, can lead to disorders involving bleeding. In my case it was a serious GI bleed, and I have been advised by my gastroenterologist that with that history (which happened when I was on the aspirin regime) the risks may outweigh the potential benefits.
4
It reminds me of big pharma and fatal condition drugs (e.g. cancer drugs). They will go to great lengths to develop a new drug which is hailed (and marketed) to be much better than the previous drug and can cost a fortune for a year's supply but if one looks behind the curtain, one finds out that the result was a barely statistically significant increase in longevity counted in days or maybe a month compared to the previous version.
39
You are mostly correct, and as an oncology nurse practitioner, there are many, many cases where I don't advocate for the new fancy drug that will only possibly increase life expectancy by weeks. But when you have a 35 year old with kids who wants a little more time.....you try saying it's probably not worth it. Treat the individual, not the statistic.
40
"Treat the individual, not the statistic."
Absolutely. But you can only do the former if you have the latter. Knowing NNT and NNH makes informed individual treatment decisions possible. After all, you need to be able to tell that 35 yr old cancer patient with kids what she can realistically expect from a treatment so that *she* can decide whether a few extra weeks is worth it or not.
While providers and the government argue about cost patients are underserved and left uninformed. And as for those providers who complain that reimbursement rates are too low, consider this: one of the largest hospital systems in NYC is based in one of the poorest congressional districts in the country, with over 80% of its patients on Medicaid or Medicare. And its CEO makes $4.5M a year. If rate are so low, where does the money come from to pay ONE person - who doesn't even provide care - more than every Ivy League university president in the nation?
I'll believe that reimbursement rates are too low when a doctor actually files for bankruptcy.
Absolutely. But you can only do the former if you have the latter. Knowing NNT and NNH makes informed individual treatment decisions possible. After all, you need to be able to tell that 35 yr old cancer patient with kids what she can realistically expect from a treatment so that *she* can decide whether a few extra weeks is worth it or not.
While providers and the government argue about cost patients are underserved and left uninformed. And as for those providers who complain that reimbursement rates are too low, consider this: one of the largest hospital systems in NYC is based in one of the poorest congressional districts in the country, with over 80% of its patients on Medicaid or Medicare. And its CEO makes $4.5M a year. If rate are so low, where does the money come from to pay ONE person - who doesn't even provide care - more than every Ivy League university president in the nation?
I'll believe that reimbursement rates are too low when a doctor actually files for bankruptcy.
3
Can't agree more. My 45 year old wife got a few extra months of quality life preparing our 5 and 7 year old for her inevitable departure from this world. Without it, we'd be in therapy.
3
After reading another NY Times article today regarding the fight for a man's guardianship to take care of his wife with dementia, in a nursing home.....
it really puts a damper on all these preventative causes anyhow. I mean, what's the use? The writing on the wall is pretty dim.
it really puts a damper on all these preventative causes anyhow. I mean, what's the use? The writing on the wall is pretty dim.
23
The NNT of demented patient who will appear better to their loved ones from taking aricept and namenda is also near infinite!!!! Those drugs only improve ability on one specific test by about 10% - not on any of the several other tests given and they do not change caregiver perceptions at all.
3
Well, at least she made it into a nursing home. Sure, we fail at some point, but most people who reach old age enjoy many happy years before they become feeble, frequently in their 80's, and die not long after they do.
2
Anything but a windfall for Big Phrama.
6